http://journals.lww.com/jrnldbp/pages/collectiondetails.aspx?TopicalCollectionId=6
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http://journals.lww.com/jrnldbp/Fulltext/2008/12000/The_Impact_of_Experience_on_Children_s.10.aspx
Objective: This study examined how 7 to 8-year-old and 11 to 12-year-old children with and without attention-deficit hyperactivity disorder (ADHD) interpreted the causes and treatment of ADHD and colds. We also examined the complexity of children’s explanations of medications for ADHD and colds.
Methods: A semi-structured interview was used to assess children’s understanding of ADHD and colds. Interviews were coded separately for each of 3 categories: principles (e.g., biological or psychological) used to explain cause and treatment; ideas about the intentionality of symptoms; and articulation of mechanisms underlying the action of medications.
Results: Younger children without ADHD demonstrated a belief that children with ADHD have control over and choose to exhibit their symptoms. Younger children with ADHD used nonintentional psychology (e.g., learning or early childhood experiences) or biological principles in their responses whereas older children with ADHD combined both of these categories in their accounts of ADHD. Older children without ADHD favored purely biological explanations of ADHD. Both age and experience were related to the complexity of children’s responses to questions about the action of medications for ADHD and colds.
Discussion: Findings highlight the need for educational interventions to rework the notion that children with ADHD intentionally display their symptoms. Educational interventions should clearly be tailored to children’s developmental level as well as their experience with a condition.]]>Mon, 03 Jan 2011 21:30:45 GMT-06:0000004703-200812000-00010http://journals.lww.com/jrnldbp/Fulltext/2008/08000/Combined_Type_Versus_ADHD_Predominantly.4.aspx
Objective: The purpose of this study was to evaluate whether preschool children with attention-deficit/hyperactivity disorder predominantly hyperactive-impulsive type (ADHD-HI) and ADHD combined type (ADHD-C) have different levels of functional impairment in four domains: externalizing (oppositional and disruptive) behaviors, internalizing (anxious) behaviors, social skills, and preacademic functioning.
Methods: The subjects were 102 children 3 to 5 years of age, meeting DSM-IV criteria for ADHD. Children with ADHD-C versus ADHD-HI were compared across at least two measures for each of the four functional domains. Oppositional and anxious behaviors were assessed on the Conners Parent and Teacher Rating Scales. In addition, off-task and disruptive behaviors were assessed by direct observation in the preschool setting. Social skills were assessed on the parent and teacher versions of the Social Skills Rating System and preacademic skills were assessed on the letter word identification, passage comprehension, and applied problems subtests of the Woodcock-Johnson III Tests of Achievement and the initial sound fluency subtest of the Dynamic Indicators of Basic Early Literacy Skills 5th Edition.
Results: There were no significant differences between the groups on rating scale T scores for parent-reported oppositional symptoms (ADHD-C vs ADHD-HI; 66.7 ± 13.5 vs 65.7 ± 11.7; p = .73); parent-reported anxious symptoms (53.5 ± 11.1 vs 53.2 ± 9.7; p = .90); teacher-reported oppositional symptoms (70.9 ± 15.6 vs 75.5 ± 14.7; p = .17); or teacher reported anxious symptoms (59.2 ± 11.6 vs 58.5 ± 12.2; p = .77). No statistically significant differences were found between the groups when examining off-task and/or disruptive behavior during structured and free play observations at school. No significant differences between the subtypes were found for social skills or preacademic functioning.
Conclusions: Across the four areas of functioning assessed in this study, preschool children with ADHD-HI and those with ADHD-C demonstrated similar levels of functioning. This study, in combination with data from longitudinal studies demonstrating that most children with ADHD-HI are later diagnosed with ADHD-C, suggests that ADHD-HI may represent an earlier form of ADHD-C as opposed to a distinct subtype.]]>Mon, 03 Jan 2011 21:31:39 GMT-06:0000004703-200808000-00004http://journals.lww.com/jrnldbp/Fulltext/2006/10000/ADHD__New_Pharmacological_Treatments_on_the.8.aspx
ABSTRACT. Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder affecting school-age children. In many cases, symptoms persist into adolescence and adulthood, causing significant lifelong impairments in academic, career, and social functioning. The stimulants methylphenidate and amphetamines have been used for decades as first-line therapy for the treatment of ADHD. Short-acting stimulant formulations control symptoms only for a few hours, creating the need for multiple daily doses of the medication. For school-age children, this necessitates administering medication during school hours, creating the potential for embarrassment and noncompliance. To offset these problems, longer acting stimulant formulations have been developed. Long-acting medications often control symptoms for up to 8 hours with only one daily dose of the medication, eliminating the need for in-school administration. Some long-acting stimulants are designed to control symptoms for up to 10 to 12 hours. Although stimulants are effective in most cases, some children are unable to tolerate these medications. Nonstimulant options are available for the treatment of ADHD and include atomoxetine, α-adrenergic agents, and antidepressants. Of these, atomoxetine is the only medication approved to treat ADHD. In spite of the number of medications available for the management of ADHD, treatment options with greater flexibility and reduced side effects are still desirable. A transdermal methylphenidate patch has recently been approved, and advances to existing stimulants currently under development include an amphetamine prodrug and a longer acting formulation of amphetamine. In addition, a number of nonstimulant entities, including guanfacine and modafinil, are under development for the treatment of ADHD.]]>Mon, 03 Jan 2011 21:32:29 GMT-06:0000004703-200610000-00008http://journals.lww.com/jrnldbp/Fulltext/2007/10000/The_Struggle_to_Assure_Equal_Treatment_for_All.11.aspx
This commentary considers the impact of applying IRT to a parent-report measure of ADHD for the purposes of reducing racial disparities in the instrument’s performance. It dwells on the difficulties of assessing complex, dynamic conditions such as ADHD and the particular problems presented by cultural variations in how the condition presents itself and informants view the behaviors tied to it.]]>Mon, 03 Jan 2011 21:33:13 GMT-06:0000004703-200710000-00011http://journals.lww.com/jrnldbp/Fulltext/2010/04001/Juan__A_9_Year_Old_Latino_Boy_With_ADHD.16.aspx
CASE: Juan, a 9-year-old Latino male, was referred to a community clinic by his third-grade teacher for evaluation of classroom behavior problems. He is an only child and lives with both parents. At home, Juan speaks Spanish with his parents although he occasionally speaks English with his father. His father came to the U.S. from Mexico as a small child and completed the 12thgrade in the U.S. Juan's mother completed 8th grade in Mexico and immigrated to the U.S. as a teenager.
Juan's mother reported that he has had no significant medical problems. Her report of his behavior included an inability to focus on tasks at hand and easy distractibility. She was concerned that the principal of the school mentioned that Juan may be asked to repeat the 3rd grade or change schools. In the clinic, Juan sat quietly but appeared to be daydreaming and attentive to the conversation.
The pediatrician called the principal who expressed frustration with Juan's behavior. In class, he was very fidgety, did not pay attention and usually did not answer questions.
He also bothered other students when they were working. The principal explained that because Juan's school was a Spanish language immersion school, there were no special education services available. If a student at the school required special education services, he or she would be transferred to another school in the same school district.
An evaluation for an Individualized Education Plan (IEP) indicated that Juan had above average cognitive ability (90th percentile), with superior ability to problem solve and process information simultaneously (99th percentile). The Woodcock Johnson III (Spanish version) indicated average achievement in academic skills, with low average in reading fluency, comprehension and spelling. On the Test of Auditory-Perceptual Skills, Juan tested generally low average in all domains, and was at the 14 percentile for both auditory number and auditory word memory. On the Test of Visual-Perceptual Skills, Juan scored above the 92nd percentile. Juan did not qualify for special education services on the basis on the standardized tests. However, because of the individual attention required by Juan, a transfer to another school was considered inevitable if his classroom behaviors did not improve.
Juan's mother and teacher filled-out the NICHQ Vanderbilt Assessment Scale. Their responses were consistent with the diagnosis of ADHD, inattentive type. In discussion of treatment options with the family, the possibility of stimulant medication use was raised. Juan's mother was opposed to the medication because of what she had heard from her friends—that these medications had bad side effects and did not work most of the time. Juan's father, however, was in favor of the medication because it might assist Juan to stay at the school. After several clinical visits that included further information about ADHD, behavioral treatment, and reviewing information from the school, Juan's parents agreed to a trial of medication.
Juan was evaluated for a follow-up visit 2 weeks after starting fourth grade; he had been taking a stimulant medication for one month. He seemed much happier about school and was proud to report that he has completed all of his assignments in school as well as homework assignments, and he did well on a math quiz. Juan's mother was also pleased with his progress.
The pediatrician called the principal, who reported that Juan was an entirely different student. He now sat at his desk and wrote down the assignments. He seemed eager to learn and able to be attentive in the classroom. The principal was amazed at the difference.]]>Mon, 03 Jan 2011 21:34:06 GMT-06:0000004703-201004001-00016http://journals.lww.com/jrnldbp/Fulltext/2010/04001/ADHD,_Medication_and_the_Military_Service__A.17.aspx
CASE: 19-year old male was admitted to a trauma service after falling from a height of 20 feet while rope climbing during military basic training activity. He climbed to the top of the rope but was unable to navigate a series of other activities at the top, became distracted, and fell. He sustained superficial injuries but was admitted to the hospital for observation. An Adolescent Medicine consult was obtained consistent with the trauma service protocol. During that consultation, a comprehensive past medical history was initially negative. On further inquiry however, when asked “Are you supposed to take any medications?” the patient revealed that several years earlier he was diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). Medication at that time was associated with improvement in school performance. He progressed from being a poor student to successfully completing freshman year at college prior to enlistment. He knew medication for ADHD would prevent enlistment, so he did not reveal the disorder or medication to his recruiter. While obtaining this history the patient was talkative, easily distracted and admitted that his concentration and ability to follow instructions was significantly enhanced on medication.
For a consultant, the dilemma became how to handle this potentially important piece of history. Inability to follow instructions may have contributed to this hospitalization and had the potential to put him and his colleagues in greater future jeopardy. Revealing this history might also cause discharge from the military.]]>Mon, 03 Jan 2011 21:34:31 GMT-06:0000004703-201004001-00017http://journals.lww.com/jrnldbp/Fulltext/2007/08000/Are_Girls_with_ADHD_at_Risk_for_Eating_Disorders_.7.aspx
Objective: To evaluate the association between attention-deficit/hyperactivity disorder (ADHD) and eating disorders in a large adolescent population of girls with and without ADHD.
Method: We estimated the incidence of lifetime eating disorders (either anorexia or bulimia nervosa) using Cox proportional hazard survival models. Comparisons between ADHD girls with and without eating disorders were then made on measures of comorbidity, course of ADHD, and growth and puberty.
Results: ADHD girls were 3.6 times more likely to meet criteria for an eating disorder throughout the follow-up period compared to control females. Girls with eating disorders had significantly higher rates of major depression, anxiety disorders, and disruptive behavior disorder compared to ADHD girls without eating disorders. Girls with ADHD and eating disorders had a significantly earlier mean age at menarche than other ADHD girls. No other differences in correlates of ADHD were detected between ADHD girls with and without eating disorders.
Conclusions: ADHD significantly increases the risk of eating disorders. The presence of an eating disorder in girls with ADHD heightens the risk of additional morbidity and dysfunction.]]>Mon, 03 Jan 2011 21:35:08 GMT-06:0000004703-200708000-00007http://journals.lww.com/jrnldbp/Fulltext/2009/02000/The_Utility_of_a_Continuous_Performance_Test.2.aspx
Objective: Continuous performance tasks (CPT) are popular in the diagnostic process of Attention Deficit/Hyperactivity Disorder (ADHD), providing an objective measure of attention for a disorder with otherwise subjective criteria. Aims of the study were to: (1) compare the performance of children with ADHD on a CPT embedded within a virtual reality classroom (VR-CPT) to the currently used Test of Variables of Attention (TOVA) CPT, and (2) assess how the VR environment is experienced.
Methods: Thirty-seven boys, 9 to 17 years, with (n = 20) and without ADHD (n = 17) underwent 3 CPT’s: VR-CPT, the same CPT without VR (No VR-CPT) and the TOVA. Immediately following CPT, subjects described their subjective experiences on the Short Feedback Questionnaire. Results were analyzed using analysis of variance with repeated measures.
Results: Children with ADHD performed poorer on all CPT’s. The VR-CPT showed similar effect sizes to the TOVA. Subjective feelings of enjoyment were most positive for VR-CPT.
Conclusion: The VR-CPT is a sensitive and user-friendly assessment tool to aid diagnosis in ADHD.]]>Mon, 03 Jan 2011 21:35:53 GMT-06:0000004703-200902000-00002http://journals.lww.com/jrnldbp/Fulltext/2007/06000/Investigating_ADHD_Treatment_Trajectories_.1.aspx
Objective: Policymakers, federal agencies, and researchers have called for more in-depth investigation of contextual mechanisms that may explain differences in medication use among youths with attention-deficit/hyperactivity disorder (ADHD).
Method: We conducted qualitative interviews with 28 families from varied socioeconomic and racial/ethnic and linguistic backgrounds regarding diagnostic and treatment trajectories for their children with symptoms consistent with ADHD, with a particular focus on whether and how medication use became a part of the trajectory.
Results: Four longitudinal patterns of help-seeking trajectories emerged: (1) a pattern characterized by delay to diagnosis, common among youths with complicated clinical and/or environmental pictures or primarily inattentive ADHD symptoms; (2) an initial nonmedication treatment pattern in which parents at first chose to use other modalities of treatment; (3) a reluctant receipt of an ADHD diagnosis and/or treatment pattern, mainly seen among the low-income, Spanish-speaking families; and (4) a rapid engagement in medication use pattern, characterized by directed movement to and maintenance of medication use. These patterns resulted from a dynamic interplay of explanatory models regarding the cause, course, and cure of a child's problems; the influence of extended social networks; and factors previously examined in medical utilization models. Additional themes included (1) parents' need for more information about ADHD, (2) families' desire for additional mental health and school services making medications less necessary, and (3) the importance of cultural sensitivity and a longitudinal relationship between the caregiver and clinician to enhance communication between families and clinicians.
Conclusions: These findings deserve further study in a larger, more diverse sample.]]>Mon, 03 Jan 2011 21:36:29 GMT-06:0000004703-200706000-00001http://journals.lww.com/jrnldbp/Fulltext/2007/04000/Effect_of_Supplementation_with_Polyunsaturated.2.aspx
Methods: Various developmental problems including attention-deficit/hyperactivity disorder (ADHD) have been linked to biological deficiencies in polyunsaturated fatty acids (PUFAs). Additionally, there is evidence that symptoms may be reduced with PUFA supplementation. This study investigated effects of supplementation with PUFAs on symptoms typically associated with ADHD. Because nutrients work synergistically, additional effects of micronutrient supplementation were also investigated. A total of 132 Australian children aged 7 to 12 years with scores ≥2 SD above the population average on the Conners ADHD Index participated in a randomized, placebo-controlled, double-blind intervention over 15 weeks, taking PUFAs alone, PUFAs + micronutrients, or placebo. Due to unreturned questionnaires, data were only available for 104 children.
Results: Significant medium to strong positive treatment effects were found on parent ratings of core ADHD symptoms, inattention, hyperactivity/impulsivity, on the Conners Parent Rating Scale (CPRS) in both PUFA treatment groups compared with the placebo group; no additional effects were found with the micronutrients. After a one-way crossover to active supplements in all groups for a further 15 weeks, these results were replicated in the placebo group, and the treatment groups continued to show significant improvements on CPRS core symptoms. No significant effects were found on Conners Teacher Rating Scales.
Conclusion: These results add to preliminary findings that ADHD-related problems with inattention, hyperactivity, and impulsivity might respond to treatment with PUFAs and that improvements may continue with supplementation extending to 30 weeks.]]>Mon, 03 Jan 2011 21:37:08 GMT-06:0000004703-200704000-00002http://journals.lww.com/jrnldbp/Fulltext/2009/12000/Executive_Function_in_Adolescence_Among_Children.7.aspx
Objective: Little is known about executive function among adolescents with a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD), and there is a lack of such information in an ethnic Chinese population. This study investigated nonverbal executive functions in adolescence among Taiwanese children with ADHD.
Methods: The sample included fifty-three 11- to 16-year-old adolescents (male, 75.5%) with a childhood diagnosis of ADHD according to the DSM-IV criteria, and 53 age-, sex-, IQ-, and parental education-matched comparison adolescents. They were assessed using psychiatric interviews (mothers included), the Weschler Intelligence Scale for Children-3rd edition, and the tasks involving the executive functions of the Cambridge neuropsychological test automated battery: the spatial span, spatial working memory, intradimensional/extradimensional shifts, and stocking of Cambridge. A linear multilevel model was used for data analysis for the matched case-control study design and repeated measures within the same participants.
Results: Forty-three adolescents (81.1%) had persistent DSM-IV ADHD diagnosis. The ADHD group made more errors in the spatial span and spatial working memory, had more complete stage trials in the intradimensional/extradimensional shifts, and had fewer problems solved and shorter initial and subsequent thinking time in the stockings of Cambridge than the controls. The magnitudes of group differences increased with increased task difficulties. Persistent ADHD and methylphenidate did not make significant difference in executive functions.
Conclusions: The findings of the authors suggest that adolescents with childhood ADHD need extra assistance when they are assigned complex tasks regardless of persistence of ADHD at adolescence.]]>Mon, 03 Jan 2011 21:37:47 GMT-06:0000004703-200912000-00007http://journals.lww.com/jrnldbp/Fulltext/2008/12000/The_Longitudinal_Course_of_Comorbid_Oppositional.13.aspx
Objective: A better understanding of the long-term scope and impact of the comorbidity with oppositional defiant disorder (ODD) in girls with attention-deficit/hyperactivity disorder (ADHD) has important clinical and public health implications. However, most of the available information on the subject derives from predominantly male samples. This study evaluated the longitudinal course and impact of comorbid ODD in a large sample of girls with ADHD.
Methods: Subjects were pediatrically and psychiatrically referred girls with and without ADHD assessed blindly at baseline (mean age = 11.6 years), and 5 years later (mean age = 16.6 years) by mid to late adolescence. The subjects’ diagnostic status of ADHD with and without comorbid ODD at baseline was used to define three groups (controls [N = 107], ADHD [N = 77], ADHD + ODD [N = 37]). Outcomes were examined using logistic regression (for binary outcomes) and linear regression (for continuous outcomes).
Results: Compared with girls who had ADHD only, those with ADHD + ODD at baseline had a significantly increased risk for ODD and major depression at follow-up. Both groups of girls with ADHD had an increased risk for conduct disorder and bipolar disorder at follow-up.
Conclusions: These longitudinal findings in girls with ADHD support and extend previously reported findings in boys indicating that ODD heralds a compromised outcome for girls with ADHD in adolescence.]]>Mon, 03 Jan 2011 21:38:28 GMT-06:0000004703-200812000-00013http://journals.lww.com/jrnldbp/Fulltext/2007/04000/Symptoms_of_Attention_Deficit_Hyperactivity.6.aspx
Methods: We investigated changes in inattentive and hyperactive symptoms over 2 years following traumatic brain injury (TBI) in relation to preinjury attention-deficit/hyperactivity disorder (ADHD), injury, and socioeconomic status (SES) variables. Postinjury stimulant medication treatment was also documented. Of 175 consecutive patients of ages 5 to15 years with acute TBI, 148 consented, including 114 without preinjury ADHD (mean age, 10.0 years, SD = 2.76) and 34 with preinjury ADHD (mean age 10.36 years, SD = 2.75). The Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version, was administered at baseline and at 6, 12, and 24 months post-injury to assess the presence of nine core inattentive and nine hyperactive symptoms and associated impairment. The baseline assessment was performed within 1 month post-injury to establish preinjury diagnosis.
Results: Nonlinear change in inattentive symptoms in patients without preinjury ADHD contrasted with higher and more stable symptom levels in children with preinjury diagnosis, including the cubic trend (χ21 = 6.23, p = .0126). There was also a significant interaction of group x gender effect (χ21 = 4.08, p = .0435) as males had higher numbers of inattentive symptoms than females in the preinjury ADHD group. Change in hyperactive symptoms over time also differed by group, including both linear (χ21 = 5.42, p = .0199) and cubic trends (χ21 = 8.91, p = .0029), reflecting greater and more frequent fluctuations in children without preinjury ADHD. Socioeconomic level also contributed to change in hyperactive symptoms as reflected by the interaction of SES and linear time (χ21 = 6.91, p = .009), as well as quadratic time (χ21 = 4.90, p = .027). Occurrence of ADHD diagnosed post-injury ranged from 14.5% (12 months) to 18.3% (24 months) in the group without preinjury ADHD compared with a range from 86.4% (12 months) to 96.2% (6 months) in children with preinjury ADHD. In children without preinjury ADHD, SES was the only patient variable that predicted onset of ADHD, t(110) = −2.85, p = .0052. Treatment with stimulant medication post-injury was more frequently associated with preinjury ADHD (39% vs 7% of children without preinjury ADHD), p< .0001 (Fisher exact test). Children with preinjury ADHD who were treated pre-injury with stimulant medication had fewer total symptoms at 24 months post-injury relative to untreated patients with preinjury ADHD (F[1,14] = 3.93, p = 0.069, Cohen’s d = 1.28).
Conclusion: Change in ADHD symptoms after TBI varies with preinjury diagnosis, reflects injury severity in children without preinjury ADHD, and is treated with stimulant medication mainly in those patients with preinjury ADHD.]]>Mon, 03 Jan 2011 21:39:09 GMT-06:0000004703-200704000-00006http://journals.lww.com/jrnldbp/Fulltext/2006/02000/Long_Term_Stimulant_Medication_Treatment_of.1.aspx
ABSTRACT. The purpose of this study was to offer detailed information about stimulant medication treatment provided throughout childhood to 379 children with research-identified attention-deficit hyperactivity disorder (ADHD) in the 1976-1982 Rochester, MN, birth cohort. Subjects were retrospectively followed from birth until a mean of 17.2 years of age. The complete medical record of each subject was reviewed. The history and results of each episode of stimulant treatment were compared by gender, DSM-IV subtype of ADHD, and type of stimulant medication. Overall, 77.8% of subjects were treated with stimulants. Boys were 1.8 times more likely than girls to be treated. The median age at initiation (9.8 years), median duration of treatment (33.8 months), and likelihood of developing at least one side effect (22.3%) were not significantly different by gender. Overall, 73.1% of episodes of stimulant treatment were associated with a favorable response. The likelihood of a favorable response was comparable for boys and girls. Treatment was initiated earlier for children with either ADHD combined type or ADHD hyperactive-impulsive type than for children with ADHD predominantly inattentive type and duration of treatment was longer for ADHD combined type. There was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response, but dextroamphetamine was more likely to be associated with side effects. These results demonstrate that the effectiveness of stimulant medication treatment of ADHD provided throughout childhood is comparable to the efficacy of stimulant treatment demonstrated in clinical trials.]]>Mon, 03 Jan 2011 21:39:46 GMT-06:0000004703-200602000-00001http://journals.lww.com/jrnldbp/Fulltext/2009/10000/Tourette_Syndrome_Associated_Psychopathology_.9.aspx
Objective: Individuals with Tourette syndrome (TS) often display comorbid symptoms of attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD), as well as externalizing and internalizing behaviors. This study was aimed to examine the impacts of tic severity, ADHD symptoms, and OCD on internalizing (e.g., anxiety) and externalizing (e.g., aggression) psychopathology.
Methods: Using linear regressions, we examined how tics, ADHD, and OCD symptoms predicted the externalization and internalization behaviors measured by the Child Behavior Checklist in a clinical sample of children and adolescents with TS. In addition, Child Behavior Checklist scales were compared among children with TS without ADHD, TS and ADHD, ADHD without TS, and unaffected control group.
Results: In the TS group, externalizing behaviors were predicted by tic severity, inattention, and hyperactivity/impulsivity but not by OCD symptoms, whereas internalizing behaviors were predicted by inattention and OCD symptoms but not by tic severity or hyperactivity/impulsivity. Comparison among different clinical groups revealed main effects of TS and ADHD on both externalizing and internalizing behaviors.
Conclusion: These findings suggest that tics, ADHD, and OCD symptoms differentially explain the variance in externalizing and internalizing behavioral problems in individuals with TS. In addition, the data support the notion that TS is itself a risk factor for behavioral problems, mandating that children with TS even without ADHD and OCD still need to be assessed and treated for psychopathology.]]>Mon, 03 Jan 2011 21:40:25 GMT-06:0000004703-200910000-00009http://journals.lww.com/jrnldbp/Fulltext/2009/04000/Prenatal_and_Perinatal_Morbidity_in_Children_with.2.aspx
Objective: Tourette syndrome (TS) and attention-deficit hyperactivity disorder (ADHD) are frequently seen in combination, though the cause of comorbidity is uncertain. Low birth weight is a known risk factor for ADHD. The objective of the study was to assess the association between pre- and perinatal morbidity and the comorbid diagnosis of ADHD in children with TS.
Method: A nested case-control study of children evaluated for TS at a subspecialty clinic was performed. Cases were defined as children with TS and ADHD; controls had TS without ADHD. Exposure to pre- and perinatal morbidity was assessed using demographic information booklets completed by parents before the diagnostic interview.
Results: Three hundred fifty-three children were included, 181 cases and 172 controls. Children with TS and ADHD had a greater odds of exposure to low birth weight status, prematurity, breathing problems, and maternal smoking compared with children with TS only. A multivariable logistic regression model found adjusted odds ratios for the comorbid diagnosis of TS and ADHD of 2.74 (95% CI 1.03–7.29, p = .04) in children born low birth weight, and of 2.43 (95% CI 1.23–4.82, p = .01) for children exposed to maternal smoking.
Conclusion: In children with TS, there is a greater odds of comorbid ADHD in children born with low birth weight or with exposure to maternal smoking. The commonality of risk factors for ADHD only and tic-related ADHD supports a common underlying neurobiology. Women with fetuses at risk for TS should avoid smoking and preventable causes of low birth weight to minimize the risk of comorbid ADHD.]]>Mon, 03 Jan 2011 21:41:08 GMT-06:0000004703-200904000-00002http://journals.lww.com/jrnldbp/Fulltext/2006/06000/Parent_and_Teacher_Rating_Scales_in_the_Evaluation.6.aspx
ABSTRACT. This study evaluated diagnostic utility of parent and teacher ratings in the attention-deficit hyperactivity disorder (ADHD) assessment and differential diagnosis of a clinical sample of children referred for suspected ADHD. Participants were 184 5- to 12-year-old children for whom the following were available: multimethod multi-informant assessment, firm decision regarding presence or absence of ADHD, and parent-completed Child Behavior Checklist and revised 48-item Conners Parent Rating Scale, and teacher-completed Teacher Report Form and 39-item Conners Teacher Rating Scale. Parent ratings of children diagnosed with and without ADHD were generally similar. In contrast, teachers rated students diagnosed with ADHD as displaying higher levels of behavioral difficulties. Discriminant function analyses indicated parent ratings of narrowband measures of ADHD and broadband measures of externalizing symptoms displayed high sensitivity. Teacher ratings outperformed parent ratings when considering sensitivity, specificity, and overall classification accuracy. For clinically recommended cut scores, teacher measures displayed good specificity and positive predictive power. Combining rating scales within informants. did not improve classification accuracy. Combining across parent and teacher measures produced results consistent with teacher ratings. Results support recommendations to include parent and teacher rating scales in ADHD assessment. Scales contributing most to classification accuracy were those designed to assess ADHD. Imperfect performance of rating scales supports recommendations to include other methodologies in diagnosis and differential diagnosis of ADHD.]]>Mon, 03 Jan 2011 21:41:50 GMT-06:0000004703-200606000-00006http://journals.lww.com/jrnldbp/Fulltext/2010/06000/A_Review_of_Attention_Deficit_Hyperactivity.10.aspx
Background: Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent disorder with significant functional impairment. ADHD is frequently complicated by oppositional symptoms, which are difficult to separate from comorbidity with oppositional defiant disorder, conduct disorder, and aggressive symptoms. This review addresses the impact of oppositional symptoms on ADHD, disease course, functional impairment, clinical management, and treatment response.
Review of clinical evidence: Oppositional defiant disorder or conduct disorder may be comorbid in more than half of ADHD cases and are more common with the combined than with the inattentive ADHD subtype. Comorbid symptoms of oppositional defiant disorder and conduct disorder in patients with ADHD can have a significant impact on the course and prognosis for these patients and may lead to differential treatment response to both behavioral and pharmacologic treatments.
Impact on clinical management: Assessment of oppositional symptoms is an essential part of ADHD screening and diagnosis and should include parental, as well as educator, input. Although clinical evidence remains limited, some stimulant and nonstimulant medications have shown effectiveness in treating both core ADHD symptoms and oppositional symptoms.
Conclusions: Oppositional symptoms are a key consideration in ADHD management, although the optimum approach to treating ADHD complicated by such symptoms remains unclear. Future research should focus on the efficacy and safety of various behavioral and medication regimens, as well as longitudinal studies to further clarify the relationships between ADHD, oppositional defiant disorder, and conduct disorder.]]>Mon, 03 Jan 2011 21:42:25 GMT-06:0000004703-201006000-00010http://journals.lww.com/jrnldbp/Fulltext/2010/10000/Use_of_Antidepressants_During_Pregnancy_and_Risk.2.aspx
Objective: Little is known about the impact of in utero exposure to antidepressants on children's long-term mental health. This study analyzed the impact of exposure to antidepressants during pregnancy on the risk of attention-deficit/hyperactivity disorder (ADHD) in the offspring.
Methods: Claims-based data from 38,074 families were used to identify deliveries, parental mental health diagnoses, maternal exposure to antidepressants, and diagnosis or treatment for ADHD in the children. Multiple logistic regressions were performed using the presence of ADHD in the child by the age of 5 years as the dependent variable.
Results: A diagnosis of ADHD in the mother or the father was associated with higher rates of ADHD in the children (OR = 4.15, p Mon, 03 Jan 2011 21:43:57 GMT-06:0000004703-201010000-00002http://journals.lww.com/jrnldbp/Fulltext/2007/10000/Psychiatric_Features_and_Parenting_Stress_Profiles.3.aspx
Objective: This study attempts to evaluate whether there are attention deficit/ hyperactivity disorder (ADHD) subtype differences regarding psychiatric features, comorbidity pattern and parenting stress profiles in an Asian population.
Methods: A total of 182 ADHD children and their primary caretakers recruited from a university-affiliated hospital were surveyed. Subjects were two groups of preadolescent (6 to 12 years old) ADHD children: children with ADHD-inattentive subtype (n = 58) and ADHD-combined subtype (n = 124). Various information was collected and compared, including the child's characteristics (current age, gender, number of family members, age at ADHD diagnosis, duration of pharmaceutical intervention, psychiatric comorbidities, and intelligence quotient); the primary caretaker's characteristics, and profiles obtained with the Parenting Stress Index (PSI).
Results: Group comparison showed that these two subtypes were statistically distinguishable from each other in total scores on the PSI, four subscale scores on the PSI, the child's age at diagnosis, and comorbidity profiles (all p < .05). Parents of children of the combined subtype experienced higher parenting stress and felt their children displayed qualities that made it difficult for them to fulfill their parenting roles. School failure (p = .001) and anxiety disorders (p = .022) were significantly more prevalent in the inattentive subtype children, while oppositional defiant disorder was significantly more present in the combined subtype children (p = .000).
Conclusions: Our findings supported the cross-cultural equivalence of the nosological distinction in ADHD subtypes. The need for specific clinical intervention according to the subtype difference was stressed.]]>Mon, 03 Jan 2011 21:45:10 GMT-06:0000004703-200710000-00003http://journals.lww.com/jrnldbp/Fulltext/2007/10000/Racial_Differences_in_Parental_Reports_of.1.aspx
Objective: Accurate assessment of racial disparities in attention-deficit/hyperactivity disorder (ADHD) depends on measurement that is equally valid for all groups. This study examines differences among African American and white children in ADHD measurement with a widely used parental report instrument, the Diagnostic Interview Schedule for Children (DISC).
Methods: Data come from 1070 children in the Fast Track Project, a longitudinal study of predominantly low-income children at risk of emotional and/or behavioral problems. Item Response Theory (IRT) methodology is used to determine whether ADHD screening items provide comparable information for African American and white children or whether differential item function (DIF) exists. IRT scores and race/ethnicity are entered in logistic regression models predicting use of ADHD medication.
Results: Seven of 39 DISC items performed differently among African Americans and whites. In most cases, parents of white children were more likely to endorse these items than were parents of African American children at comparable underlying levels of children's hyperactivity. When items exhibiting differential functioning were deleted, race disparities predicting underlying need as indicated by ADHD medication use decreased and were no longer statistically significant.
Conclusions: Perceptions of ADHD-related symptoms among parents of African American children appear to differ in important ways from those of parents of white children, and screening instruments relying on parent report may yield different results for African American and white children with similar underlying treatment needs. Gathering information from additional sources including teachers and school counselors can provide a more complete picture of the behavioral functioning and therapeutic needs of children in all race/ethnic groups.]]>Mon, 03 Jan 2011 21:45:53 GMT-06:0000004703-200710000-00001http://journals.lww.com/jrnldbp/Fulltext/2010/04001/Discovering_Gifted_Children_in_Pediatric_Practice.18.aspx
CASE: Casey is a first grader who is brought to the pediatrician for consideration of ADHD. His mother is concerned that he is very difficult to focus at home when asked to do anything and gets so distracted at meals that he eats very little. The teachers last year and this year say that Casey is very distracted, always “in a fog” and just can't seem to get his work done. “He's in his own world.” His report card has several unsatisfactory marks because of poor completion of work, doing things other than the assignment and talking too much to the kids around him. The parents are very upset as they see their son as very bright. His advanced vocabulary, early reading skills and his extensive knowledge of engines, machines and aircraft were all noted in his medical chart in the past as part of his health supervision visits. He has lots of friends, mostly third graders and plays soccer with moderate success. The paternal grandmother says Casey is just like his dad who is now a biochemical geneticist. He too had a hard time getting his work in as a child and “always talked back” to the teacher. Casey's mother would like him on medication before the Iowa Basics come around. The Vanderbilt rating scales by both teacher and parent are positive for inattention and borderline for hyperactivity. Casey took it upon himself to speak to the principal about how bored he was with the classroom work. She agreed that he could have some special assignments.
In the pediatrician's office, Casey is a delightful, verbal, thin boy who has about 100 things to talk about, from train engines to the sports scores, acquired from the television sports channel, to what should be done to “fix” his school. He said he was bored and knew more about volcanoes than the science teacher. He just wanted to get home each day and work on his elaborate train setup. He doesn't seem overly active, distractible, anxious, inattentive or oppositional. Testing by the school psychologist showed him to have an IQ of 138 with an even verbal/performance profile.
Sam is a 4-year old whose parents brought him to the local private school for application to kindergarten. The admission requirements consisted of a group “developmental” test, given to groups of 20 youngsters at a time. Sam failed the test. The report said that he was too immature, talked out of turn and generally wasn't ready for the vigorous academic program planned at that school. He asked too many questions and argued with the admissions person. They suggested he might need medication before he attempted school. His parents asked their pediatrician for an opinion on the school report. They asked for a referral for testing as they could not believe their son was a preschool failure. The psychologist reported that his IQ was 142 (verbal 146 and performance 136).]]>Mon, 03 Jan 2011 21:59:31 GMT-06:0000004703-201004001-00018http://journals.lww.com/jrnldbp/Fulltext/2008/08000/Pediatricians__Role_in_Providing_Mental_Health.3.aspx
Background: Many children who have a mental health disorder do not receive mental health services and are seen only in primary care settings. Perceptions of pediatricians and mental health specialists regarding the role that pediatricians should have in diagnosing and managing children's mental health problems have not been studied.
Objective: To examine whether primary care pediatricians (PCPs) and child and adolescent psychiatrists (CAPs) agree about: (1) the pediatrician's role in identification, referral, and treatment of childhood mental health (MH) disorders; and (2) barriers to the identification, referral, and treatment of childhood MH disorders.
Methods: Surveys were mailed in 2005 to 338 PCPs and 75 CAPs in 7 counties surrounding Cleveland, Ohio. Each group was asked whether they agreed that PCPs should be responsible for identifying, treating, or referring 7 prevalent childhood MH problems. Barriers that PCPs face in identification, referral, and treatment of MH problems were also assessed. Analyses were weighted for nonresponse; group differences were assessed via Rao-Scott χ2 test and weighted regression analyses.
Results: Approximately half of PCPs and CAPs returned the survey. With the exception of attention deficit hyperactivity disorder (ADHD), the majority of PCPs and CAPs agreed that pediatricians should be responsible for identifying and referring, but not treating child MH conditions. For ADHD, PCPs were more likely than CAPs to agree that pediatricians should identify and treat affected children. PCPs were more likely than CAPs to agree that pediatricians should be responsible for identifying child/adolescent depression and anxiety disorders; the majority of both groups agree that PCPs should be responsible for referring, but not treating these conditions. Both groups agree that lack of MH services is a barrier to identification, treatment, and referral of child MH problems for PCPs. CAPs were more likely to agree that pediatrician's lack of training in identifying child mental health problems was a barrier, whereas PCPs were more likely to endorse lack of confidence in their ability to treat child MH problems with counseling, long waiting periods to see MH providers, family failure to follow through on referrals, and billing/reimbursement issues as barriers.
Conclusions: Most PCPs and CAPs believe it is pediatricians' responsibility to identify and refer, but not treat, the majority of children's mental health problems. Both groups agree that mental health services are not readily available. Future efforts are needed to support PCPs and CAPs in their combined effort to address the mental health needs of children.]]>Mon, 03 Jan 2011 22:01:36 GMT-06:0000004703-200808000-00003http://journals.lww.com/jrnldbp/Fulltext/2010/04001/Disruptive_and_Oppositional_Behavior_in_an_11_Year.8.aspx
CASE: Tony is an 11-year old boy in the fifth grade whose mother describes him as “really a good kid who is bright and tries to be friendly. But he's always doing things that get him in trouble at school and sometimes at home.” Tony was diagnosed with ADHD (combined type) 2 years ago. Stimulant therapy improved his attention and concentration during school, decreased hyperactivity in the classroom and improved educational achievements. However, Tony is oppositional and disruptive on the playground, during team sports and at home. His teacher observed that he wants to fit in, but he quickly gets in arguments with other children. He has difficulty sustaining friendships because he typically annoys others with unreasonable demands. He often has temper tantrums when things do not go his way; the tantrums are not prolonged but frequent. At home, on several occasions Tony hit his younger sister, and he once threw a dinner plate against the wall during a family meal. Although his mother describes these behaviors as present for many years, they seem to be escalating. Tony lives with both parents and his younger sister. There is no history of marital discord or major life event change in the past year. Standardized achievement tests demonstrate average to above average achievement scores. He continues to get mostly B grades and an occasional C. Tony's parents have tried to limit television time as a punishment for disruptive behaviors without any apparent effect. His mother reports that she yelled at him on several occasions when he refused to carry out household chores. “He gets angry at the simplest request for help.” After meeting with Tony and his mother and completing a normal physical examination, the pediatrician referred Tony to a child psychologist for behavioral therapy.]]>Mon, 03 Jan 2011 22:03:06 GMT-06:0000004703-201004001-00008http://journals.lww.com/jrnldbp/Fulltext/2006/04002/Autism_Spectrum_Disorders_and.12.aspx
ABSTRACT. Fragile X syndrome (FXS) is caused by a full mutation expansion (>200 CGG repeats) in the FMR1 gene that results in a deficiency of the fragile X mental retardation protein. Although most individuals with the premutation (55-200 CGG repeats) are considered unaffected by FXS, recent case studies have documented children with the premutation who have cognitive deficits, behavioral problems, and/or autism spectrum disorders. The objective of this study was to compare the prevalence of autism spectrum disorders (ASD) and attention-deficit hyperactivity disorder (ADHD) symptoms in boys with the premutation who presented as probands, in brothers with the premutation who did not present as probands, and in normal brothers of premutation and/or full mutation carriers. Participants included 43 male children: 14 probands who presented to clinic, 13 nonprobands who were identified through cascade testing (routine genetic testing of family members after identification of a proband) and confirmed to have the premutation, and a control group of 16 male siblings of individuals with the fragile X premutation or full mutation who were negative for the FMR1 mutation. Participants came from 1 of 2 collaborative sites: University of California, Davis and La Trobe University in Australia. Parents completed the Conners' Global Index-Parent Version for assessing symptoms of ADHD and the Social Communication Questionnaire (SCQ) for identifying symptoms of ASD. Children who were in the ASD range on the SCQ (n = 13) underwent further evaluation with either the Autism Diagnostic Observation Schedule-Generic (n = 10) or the Autism Diagnostic Interview-Revised (n = 3). A final diagnosis of ASD included clinical assessment utilizing DSM-IV-TR criteria in addition to the standardized assessments. There was a higher rate of ASD in boys with the premutation presenting as probands (p < 0.001) or nonprobands (p < .04) compared with sibling controls without the premutation. In addition, probands had a significant increase in ADHD symptoms compared with controls (p < .0001). Of the probands, 93% had symptoms of ADHD and 79% had ASD. In the nonproband premutation group, 38% had symptoms of ADHD and 8% had ASD. Thirteen percent of sibling controls had symptoms of ADHD and none had ASD. IQ scores were similar in all 3 groups (p = .13), but the use of psychotropic medications was significantly higher in probands with the premutation compared with that in controls (p < .0001). Developmental problems have been observed in premutation carriers, particularly those who present clinically with behavioral difficulties. Although this study is based on a small sample size, it suggests that premutation carriers, even those who do not present clinically, may be at increased risk for an ASD and/or symptoms of ADHD. If the premutation is identified through cascade testing, then further assessment should be carried out for symptoms of ADHD, social deficits, or learning disabilities.]]>Mon, 03 Jan 2011 22:07:25 GMT-06:0000004703-200604002-00012http://journals.lww.com/jrnldbp/Fulltext/2006/04000/Mothers__Views_on_Hyperactivity__A_Cross_Cultural.6.aspx
ABSTRACT. To examine cultural variation in mothers' perceptions of hyperactive behaviors in school-age boys, we surveyed 135 mothers in 3 ethnic groups: Puerto Rican, Central and South American, and Anglo. Mothers read or heard 8 taped vignettes of boys with behaviors related to DSM-IV hyperactivity criteria. In 50% of the vignettes, Spanish-responding mothers were less likely to consider the boys' behaviors expected than were the English-responding mothers. In 62.5% of the vignettes, Latina mothers expressed more interest in discussing behaviors with their physicians than did the Anglo mothers, and in 62.5% of the vignettes, Spanish-responding mothers expressed more interest in discussing behaviors with their physicians than did the English-responding mothers. We found no association of the 2 scores by the bicultural scale. Mothers' perception of hyperactivity boys varies both with ethnicity and language of response. Latina mothers, especially Spanish-responding mothers, seem interested in discussing children's behavior with physicians.]]>Mon, 03 Jan 2011 22:10:18 GMT-06:0000004703-200604000-00006http://journals.lww.com/jrnldbp/Fulltext/2010/09000/Understanding_the_Complex_Etiologies_of.4.aspx
Objective: This article has 2 primary goals. First, a brief tutorial on behavioral and molecular genetic methods is provided for readers without extensive training in these areas. To illustrate the application of these approaches to developmental disorders, etiologically informative studies of reading disability (RD), math disability (MD), and attention-deficit hyperactivity disorder (ADHD) are then reviewed. Implications of the results for these specific disorders and for developmental disabilities as a whole are discussed, and novel directions for future research are highlighted.
Method: Previous family and twin studies of RD, MD, and ADHD are reviewed systematically, and the extensive molecular genetic literatures on each disorder are summarized. To illustrate 4 novel extensions of these etiologically informative approaches, new data are presented from the Colorado Learning Disabilities Research Center, an ongoing twin study of the etiology of RD, ADHD, MD, and related disorders.
Conclusions: RD, MD, and ADHD are familial and heritable, and co-occur more frequently than expected by chance. Molecular genetic studies suggest that all 3 disorders have complex etiologies, with multiple genetic and environmental risk factors each contributing to overall risk for each disorder. Neuropsychological analyses indicate that the 3 disorders are each associated with multiple neuropsychological weaknesses, and initial evidence suggests that comorbidity between the 3 disorders is due to common genetic risk factors that lead to slow processing speed.]]>Mon, 03 Jan 2011 22:14:05 GMT-06:0000004703-201009000-00004http://journals.lww.com/jrnldbp/Fulltext/2008/12000/Preschool_Parent_Pediatrician_Consultations_and.9.aspx
Objective: The present study examined parents’ reports of the frequency, nature, and outcome of pediatrician consultation and interventions about significant preschool behavior problems.
Method: Parents were asked whether they consulted with their pediatric providers about disruptive behavioral problems during a longitudinal study of preschool children.
Results: Eighty 4-year-old children had parents who had consulted with their pediatricians versus 90 children whose parents did not. Children who eventually met criteria for attention-deficit hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) 2 years later, received different pediatric interventions at age 4 years than children who did not have a diagnosis, χ2 (2) = 9.28, based on parent report. Eighty-nine percent of children who were referred for evaluation or treatment by pediatricians later met criteria for ADHD or ODD. However, 56% of children who later met criteria for ADHD or ODD were not referred by age 4 years.
Conclusion: Pediatricians were able to differentiate between preschool children with transient versus persistent behavioral problems significantly better than chance, though a large number of children with behavioral problems were not provided with early assistance or referrals. Additional research is needed to obtain data directly from pediatricians about their interventions and resources for this vulnerable population.]]>Mon, 03 Jan 2011 22:17:39 GMT-06:0000004703-200812000-00009http://journals.lww.com/jrnldbp/Fulltext/2009/04000/Are_There_Placebo_Effects_in_the_Medication.10.aspx
Placebos have been shown to produce significant positive changes in several health and mental health problems, referred to as placebo effects. Although it is well established that stimulant medication is an empirically supported treatment for children with attention-deficit hyperactivity disorder (ADHD), little is known about the role of placebos in the medication treatment of children with ADHD. This article reviews existing studies that evaluate whether placebos produce significant changes in children with ADHD. Published literature and the author's own empirical work were used to evaluate whether placebo effects are present in the medication treatment of children with ADHD. There is little evidence that placebos produce significant changes in the behavior or cognition of elementary school-age children with ADHD. However, there may be significant placebo effects in adults who evaluate children with ADHD. Evidence suggests that parents and teachers tend to evaluate children with ADHD more positively when they believe the child has been administered stimulant medication and they tend to attribute positive changes to medication even when medication has not actually been administered. Several viable mechanisms for these placebo effects are suggested.]]>Mon, 03 Jan 2011 22:19:08 GMT-06:0000004703-200904000-00010http://journals.lww.com/jrnldbp/Fulltext/2010/06000/Conditioned_Placebo_Dose_Reduction__A_New.1.aspx
Objective: This study examined if pairing a placebo with stimulant medication produces a placebo response that allows children with attention-deficit hyperactivity disorder (ADHD) to be maintained on a lower dose of stimulant medication. The primary aim was to determine the efficacy, side effects, and acceptability of a novel conditioned placebo dose reduction procedure.
Method: Participants included 99 children ages 6 to 12 years with ADHD. After an initial double-blind dose finding to identify optimal dose of mixed amphetamine salts, subjects were randomly assigned to 1 of 3 treatments of 8-week duration: (a) conditioned placebo dose reduction condition (50% reduced dose/placebo [RD/P]) or (b) a dose reduction only condition (RD) or (c) a no reduction condition (full dose). The innovative conditioned placebo dose reduction procedure involved daily pairing of mixed amphetamine salts dose with a visually distinctive placebo capsule administered in open label, with full disclosure of placebo use to subjects and parents.
Results: Seventy children completed the study. There were no differences in subject retention among the 3 groups. Most subjects in the RD/P group remained stable during the treatment phase, whereas most in the RD group deteriorated. There was no difference in control of ADHD symptoms between the RD/P group and the full dose group, and both RD/P and full dose groups showed better ADHD control than the RD group. Treatment emergent side effects were lowest in the RD/P group.
Conclusion: Pairing placebos with stimulant medication elicits a placebo response that allows children with ADHD to be effectively treated on 50% of their optimal stimulant dose.]]>Mon, 03 Jan 2011 22:21:18 GMT-06:0000004703-201006000-00001http://journals.lww.com/jrnldbp/Fulltext/2010/04000/Instability_in_Teacher_Ratings_of_Children_s.1.aspx
Objective: To examine the cross-grade stability of clinically elevated teacher ratings of inattentive symptoms in 3 samples of elementary schoolchildren.
Participants and Methods: Samples 1 and 2 included 27 first graders and 24 fourth graders, respectively, identified based on clinically elevated teacher ratings of inattentive symptoms. The third sample included 28 children in grades 1 to 4 from the Multimodal Treatment Study of attention-deficit hyperactivity disorder (Multimodal Treatment Study of Children with attention-deficit hyperactivity disorder Study) with a confirmed attention-deficit hyperactivity disorder diagnosis. Teacher ratings of inattentive symptoms were completed an average of 12 to 14 months apart so that cross-grade stability of elevated ratings could be computed for each sample.
Results: In all 3 samples, clinically elevated ratings persisted for less than 50% of children and between 25% and 50% had ratings that declined to within the normative range. The decline in attention difficulties was not related to hyperactivity, oppositional behavior, or anxiety at baseline, nor was it explained by children beginning medication treatment.
Conclusions: Many elementary-aged children rated by their teachers as highly inattentive are not considered to demonstrate these problems the following year, even children with a confirmed attention-deficit hyperactivity disorder diagnosis. The instability in clinically elevated teacher ratings found across 3 independent samples highlights the importance of annual reevaluations to avoid treating children for problems that may no longer be present.]]>Mon, 03 Jan 2011 22:23:57 GMT-06:0000004703-201004000-00001http://journals.lww.com/jrnldbp/Fulltext/2010/04000/Relationships_Between_Child_Reported_Activity.10.aspx
Objective: This study examines whether elementary school-aged children can report behaviors relevant to assessing symptoms of attention-deficit/hyperactivity disorder (ADHD).
Methods: Interviews were conducted with 120 children aged 6 to 12 years and their parents across 3 waves as part of a longitudinal cohort study of ADHD detection and service use. Child self-reports obtained through the Dimensions of Temperament Scale-Revised-Child (DOTS-R-C) were correlated with parent-reported ADHD symptoms, which were assessed through DSM-IV-based instrument ratings obtained concurrently and 5 years later.
Results: The Dimensions of Temperament Scale-Revised-Child subscales Activity Level and Task Orientation demonstrate adequate internal consistency after eliminating items requiring reverse scoring. Children's self-reports of Task Orientation Problems correlate with their parents' concurrent reports of inattention, r(117) = .23, p < .05, and with parents' Wave 3 reports of inattention, r(118) = .25, p < .01 as well as hyperactivity, r(118) = .25, p < .01. Children's self-reports of Activity Level correlate with their parents' concurrent reports of hyperactivity, r(117) = .21, p < .05, as well as Wave 3 reports of hyperactivity/impulsivity, r(118) = .37, p < .001 and inattention, r(118) = .23, p < .05.
Conclusions: Findings suggest that children may be capable of producing meaningful self-reports of Activity Level and Task Orientation. We propose that the development of child-friendly self-report instruments targeting ADHD symptoms is merited to facilitate the collection of child input during ADHD assessments.]]>Mon, 03 Jan 2011 22:24:54 GMT-06:0000004703-201004000-00010http://journals.lww.com/jrnldbp/Fulltext/2010/01000/Actual_Motor_Performance_and_Self_Perceived_Motor.6.aspx
Objective: Children with attention-deficit hyperactivity disorder (ADHD) frequently experience comorbid motor problems, developmental coordination disorder. Also, children with ADHD are said to overestimate their abilities in the cognitive and social domain, the so-called “Positive Illusory Bias.” In this cross-sectional study, the relationship between actual motor performance and perceived motor competence was examined.
Method: Motor performance was assessed using the Movement Assessment Battery for Children in 100 children and adolescents (age 6–17 years), including 32 children with ADHD combined type, 18 unaffected siblings, and 50 healthy control children. ADHD was diagnosed using Parent and Teacher questionnaires and a clinical interview. Perceived motor competence and interest in the motor domain were rated with the Dutch supplement scale to Harters' Self-Perception Profile for Children, especially focusing on the motor domain (m-CBSK).
Results: Children with ADHD had poorer motor performance than unaffected siblings and control children, especially in the field of manual dexterity. However, no relationship was found between motor performance and perceived motor competence. Only children with the very lowest motor performance had a significantly lowered perception of their motor competence. Interest in the motor domain and motor self-perception was positively correlated.
Conclusion: Children with ADHD performed poorer on the Movement Assessment Battery for Children, but generally overestimated their own motor competence.]]>Mon, 03 Jan 2011 22:26:24 GMT-06:0000004703-201001000-00006http://journals.lww.com/jrnldbp/Fulltext/2010/02000/Role_of_Perinatal_Adversities_on_Tic_Severity_and.3.aspx
Objective: To investigate the role of perinatal adversities with regard to tic severity and comorbid attention deficit/hyperactivity disorder (ADHD) symptoms in children with a tic disorder.
Methods: In 75 children and adolescents with a tic disorder, we retrospectively assessed presence of pregnancy, delivery, and postnatal complications and of prenatal exposure to smoking and alcohol. Children with and without these perinatal adversities were compared regarding tic and ADHD symptom severity. Furthermore, through linear regressions, we investigated whether perinatal adversities would interact with presence in first-degree relatives of tic or any mental disorders with the tic or ADHD measure as outcome.
Results: Presence of delivery complications was related to tic severity and prenatal smoking exposure to severity of comorbid ADHD symptoms. The relationship between smoking exposure in utero and ADHD symptom severity appeared to be more pronounced in children with a positive family history of mental disorders.
Conclusion: This study provides evidence of a role for perinatal adversities in the etiology of tic disorders. Children with perinatal adversities may be vulnerable to develop more severe tics or comorbid ADHD symptoms in the presence of a positive family history of mental disorders, suggesting a role for gene-environment interactions.]]>Mon, 03 Jan 2011 22:27:39 GMT-06:0000004703-201002000-00003http://journals.lww.com/jrnldbp/Fulltext/2011/02000/Attention_Deficit_Hyperactivity_Disorder_in.5.aspx
Objective: To compare the characteristics of children with attention-deficit hyperactivity disorder (ADHD) who have high intelligence quotient (IQ) versus normal and low IQ through long-term follow-up of children with ADHD from a population-based birth cohort.
Methods: Subjects included children with research-identified ADHD (N = 379) from a birth cohort (N = 5718). Full scale IQ scores obtained between ages 6 and 18 years were used to categorize children into 3 groups: Low (IQ < 80), Normal (80 ≤ IQ < 120), and High IQ (IQ ≥ 120). Subjects were retrospectively followed up from birth until emigration, death, or high school graduation/dropout. The groups were compared on demographic characteristics, age at which ADHD case criteria were met, comorbidities, treatment, and school outcomes.
Results: There were no significant differences among children with high (N = 34), normal (N = 276), or low IQ (N = 21) and ADHD in numerous characteristics, including median age at which ADHD criteria were fulfilled (9.5, 9.7, and 9.8 years); rates of comorbid learning disorders (85.3%, 78.3%, and 76.2%), psychiatric disorders (47.1%, 50.4%, and 47.6%), and substance abuse (17.6%, 23.6%, and 19.0%); and rates of stimulant treatment (79%, 75%, and 90%). In comparison to children with normal or low IQ, those with high IQ had mothers with higher educational levels (e.g., college graduation rates 44.1%, 11.6%, and 14.3%), and higher reading achievement (median national percentiles on standardized reading tests 77.0, 42.0, and 29.0, p < 0.001).
Conclusions: These findings suggest that ADHD is similar among children with high, normal, and low IQ, although high IQ may favorably mediate some outcomes such as reading achievement. Diagnosis and treatment of ADHD are important for all children, regardless of cognitive ability.]]>Wed, 23 Mar 2011 20:07:37 GMT-05:0000004703-201102000-00005http://journals.lww.com/jrnldbp/Fulltext/2011/07000/Comorbid_ADHD_and_Anxiety_Affect_Social_Skills.1.aspx
Objective: To assess the influence of psychiatric comorbidity on social skill treatment outcomes for children with autism spectrum disorders (ASDs).
Methods: A community sample of 83 children (74 males, 9 females) with an ASD (mean age = 9.5 yr; SD = 1.2) and common comorbid disorders participated in 10-week social skills training groups. The first 5 weeks of the group focused on conversation skills and the second 5 weeks focused on social problem solving skills. A concurrent parent group was also included in the treatment. Social skills were assessed using the Social Skills Rating System. Ratings were completed by parents at pre- and posttreatment time periods.
Results: Children with ASD and children with an ASD and comorbid anxiety disorder improved in their parent reported social skills. Children with ASD and comorbid attention deficit/hyperactivity disorder failed to improve.
Conclusion: Psychiatric comorbidity affects social skill treatment gains in the ASD population.]]>Thu, 30 Jun 2011 06:50:40 GMT-05:0000004703-201107000-00001http://journals.lww.com/jrnldbp/Fulltext/2006/04000/Stimulant_Medications_and_Their_Adverse_Events_and.19.aspx
No abstract available]]>Thu, 30 Jun 2011 06:59:42 GMT-05:0000004703-200604000-00019http://journals.lww.com/jrnldbp/Fulltext/2001/10000/Identifying_Characteristics_of_Older_and_Younger.5.aspx
This study examines the manifestation of attention-deficit hyperactivity disorder (ADHD) among females of varying ages by testing the utility of particular tests to discriminate older from younger females with ADHD. A retrospective clinical chart review was conducted at a community outpatient mental health center for 75 girls from 4 to 19 years of age with a diagnosis of ADHD or subthreshold symptoms of ADHD. Signal detection methods were used to identify which variables best differentiate older (mean age = 12.06, SD = 2.61) from younger (mean age = 7.11, SD = 1.08) girls with ADHD. Girls with comorbid diagnoses of a depressive disorder and higher verbal IQ scores were more likely to be older. Overall, the findings suggest that approaches to diagnosing ADHD among females may need to be modified to include appropriate age-based criteria.
Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavior disorder in school-age children;1 however, it is a diagnosis surrounded by controversy.2 One controversial issue is the lack of diagnostic criteria based on age- and gender-specific standards.2 Until now, the diagnostic criteria for ADHD have been directed towards the diagnosis of school-age children.3-5 This brings into question the sensitivity of the diagnostic criteria for older children, in particular for females who often are diagnosed at later ages than their male peers.4,6,7 Furthermore, our wealth of knowledge about the manifestations of ADHD is based largely on studies with samples of males only, or with samples of few female participants so that analyses of gender effects or gender by age interactions would be inappropriate.8 Thus, to ensure the appropriate diagnosis and treatment of ADHD among all individuals with this disorder, we need to understand how the manifestation of this disorder can be characterized in females, especially females beyond school age.
Although ADHD in females has not been adequately investigated, some studies suggest that the expression of this disorder among females differs from males and that the differences have implications for the age at which it is diagnosed. Proportionately more females than males show symptoms consistent with the ADHD-Inattentive subtype than with the Hyperactive-Impulsive or the Combined subtype diagnosis of the DSM-IV.2,4,7 Behavioral and academic impairments associated with each subtype appear to have implications for the age at which ADHD is diagnosed. Males frequently show disruptive behaviors that are consistent with the hyperactive-impulsive subtype, and they more commonly receive a diagnosis and treatment when they are young compared to females.4,9 In contrast, females typically manifest academic problems associated with the inattentive subtype of ADHD10 and they are likely to be diagnosed at later ages.7,11,12
Further, the diagnosis of ADHD in older females may be difficult to make because it co-exists with other disorders that can emerge in females of this age. Specifically, anxiety and depression are frequently comorbid with ADHD.7 In addition, depressed individuals show deficits in attention and self-regulation that also are present among individuals with ADHD.13,14 Because females experience and report more severe symptoms of depression and anxiety than their male peers, and because the degree of this difference dramatically increases as females develop beyond school-age and continues through adulthood,15 this pattern of comorbidity may be particularly characteristic of older females with ADHD.
Finally, diagnosing ADHD in females may be difficult because our knowledge of ADHD symptoms in females is based on a few studies that use a narrow definition of the disorder. Virtually all of these studies are limited to samples of females who unequivocally surpass a diagnostic threshold for ADHD and who have ADHD as a primary diagnosis.8,16 ADHD as it is manifested in females (and males) may need to be examined with a broader definition that reflects the disorder along a continuum, including significant symptoms in both clinical and subclinical ranges. One study of a community sample of 1015 males and females showed that children with subthreshold psychiatric conditions experienced significant and chronic impairments in functioning at rates equal to that of individuals who meet criteria for a formal diagnosis of a psychiatric disorder.17 Another study of 1549 twin pairs of female adolescents found that ADHD subtype diagnoses were based on a continuum of impairment.10 These studies suggest that many females who suffer significant impairment from symptoms of ADHD not only are excluded from studies with strict criteria, but also are undiagnosed and untreated.
Strict diagnostic criteria in studies of females with ADHD also limit our knowledge about the disorder among females with a wide range of intellectual abilities. Studies of females with ADHD often limit their samples to females with IQs greater than 80.8 Our lack of knowledge about this lower range of intellectual abilities among individuals with ADHD is especially unfortunate for girls with mental retardation. At least one study has shown that they are at higher risk for ADHD compared to girls of average intelligence.18 Finally, research limited to samples that include females with ADHD diagnosed by strict criteria may not adequately represent the more prevalent population of females who receive ADHD diagnoses in health care systems not represented in studies designed for clinical trials and other standard research protocols for diagnosis and treatment.2
Taken together, the above information suggests that a greater understanding of ADHD can be attained by including a broader and more representative sample of females who present to a community mental health clinical setting for evaluation of attentional difficulties.
The purposes of this study were (1) to test the utility of particular tests in differentiating older from younger females with clinical or subthreshold diagnoses of ADHD and (2) to generate hypotheses about the manifestation of ADHD among females. A retrospective clinical chart review was conducted at a community mental health agency with one of the larger samples, with few exceptions in published research,19,20 of females with ADHD. We collected information from a variety of standardized behavioral, cognitive, and neuropsychological tests and records of standard clinical diagnostic judgments. The information was based on reports from the patients themselves, parents, teachers, and clinicians; it was analyzed using signal detection methods, a hypothesis-generating procedure. These analyses allowed us to examine the potential utility of measures commonly used in a clinical setting to identify which characteristics best differentiate younger from older girls with ADHD. Females who were 9 years old or older were compared to females who were younger than 9 years of age. The selection of these age ranges was based on empirical evidence and clinical experience that suggests that critical biological, social, and academic changes begin to occur around 9 years of age.21-24 These changes include the onset of puberty, increased independent activities at home, changing social pressures from peers, and increased requirements at school for autonomous activities.25]]>Mon, 15 Aug 2011 13:47:04 GMT-05:0000004703-200110000-00005http://journals.lww.com/jrnldbp/Fulltext/2002/02001/Preschool_Attention_Deficit_Hyperactivity.2.aspx
ABSTRACT. The clinical use of stimulant medications for 3- to 6-year-old preschool children who meet diagnostic criteria for attention deficit hyperactivity disorder (ADHD) is becoming more common. A systematic computerized literature search extending back to 1970 identified nine controlled studies of stimulant treatment and two controlled trials of stimulant side effects in preschool ADHD children. Treatment benefits are reported for eight of nine (89%) controlled stimulant trials involving a total of 206 preschool subjects. In comparison with school-aged ADHD youth, there may be a greater variability of stimulant response in ADHD preschoolers. Domains assessing cognition, interpersonal interactions, and hyperactive-impulsive behavior are noted to improve on drugs relative to placebos. Side effects in this age range are generally reported as mild. ADHD preschool children may experience slightly more and different types of stimulant-induced side effects compared with older children. High rates of behavior reported as stimulant side effects are found for children receiving a placebo, necessitating a baseline evaluation for medication side effects before stimulants are initiated. Despite the lack of research assessing stimulant effects on the very young and developing brain and the need for more controlled medication trials in this age range, this review of the extant literature finds stimulants to meet evidence based criteria as beneficial and safe for carefully diagnosed ADHD preschool children aged 3 years and older.]]>Mon, 15 Aug 2011 13:53:58 GMT-05:0000004703-200202001-00002http://journals.lww.com/jrnldbp/Fulltext/2002/02001/In_Harm_s_Way__Toxic_Threats_to_Child_Development.4.aspx
ABSTRACT. Developmental disabilities result from complex interactions of genetic, toxicologic (chemical), and social factors. Among these various causes, toxicologic exposures deserve special scrutiny because they are readily preventable. This article provides an introduction to some of the literature addressing the effects of these toxicologic exposures on the developing brain. This body of research demonstrates cause for serious concern that commonly encountered household and environmental chemicals contribute to developmental disabilities. The developing brain is uniquely susceptible to permanent impairment by exposure to environmental substances during time windows of vulnerability. Lead, mercury, and polychlorinated biphenyls (PCBs) have been extensively studied and found to impair development at levels of exposure currently experienced by significant portions of the general population. High-dose exposures to each of these chemicals cause catastrophic developmental effects. More recent research has revealed toxicity at progressively lower exposures, illustrating a “declining threshold of harm” commonly observed with improved understanding of developmental toxicants. For lead, mercury, and PCBs, recent studies reveal that background-population exposures contribute to a wide variety of problems, including impairments in attention, memory, learning, social behavior, and IQ. Unfortunately, for most chemicals there is little data with which to evaluate potential risks to neurodevelopment. Among the 3000 chemicals produced in highest volume (over 1 million lbs/yr), only 12 have been adequately tested for their effects on the developing brain. This is a matter of concern because the fetus and child are exposed to untold numbers, quantities, and combinations of substances whose safety has not been established. Child development can be better protected by more precautionary regulation of household and environmental chemicals. Meanwhile, health care providers and parents can play an important role in reducing exposures to a wide variety of known and suspected neurodevelopmental toxicants that are widely present in consumer products, food, the home, and wider community.]]>Mon, 15 Aug 2011 13:55:24 GMT-05:0000004703-200202001-00004http://journals.lww.com/jrnldbp/Fulltext/2002/02001/Five_Burning_Questions.5.aspx
No abstract available]]>Mon, 15 Aug 2011 14:05:47 GMT-05:0000004703-200202001-00005http://journals.lww.com/jrnldbp/Fulltext/2002/02001/Patterns_of_Psychopathology_and_Dysfunction_in.6.aspx
ABSTRACT. Despite the growing interest in the use of psychotropic medications in preschoolers, little is known about the clinical presentation of young children referred for psychiatric services. We describe the clinical characteristics, psychiatric disorders, and functioning of preschoolers referred for pediatric psychiatry evaluation. Structured psychiatric interviews assessing lifetime psychopathology by DSM-III-R criteria were completed on clinically referred youth. Family, social, and overall functioning were assessed at intake. From the pool of 1658 consecutive referrals, we identified 200 children less than or equal to (≤) 6 years of age (12%). The most common psychopathology identified was attention deficit hyperactivity disorder (ADHD) (86%), followed by other disruptive behavioral (61%), mood (43%), and anxiety disorders (28%). Co-occurring psychiatric disorders were common with preschoolers manifesting a mean of two major psychiatric disorders per child. Despite their young age, the onset of psychopathology preceded evaluation by a mean (±SD) of 2.2 ± 1.3 years. Preschoolers referred for psychiatric services had high rates of psychopathology with prominent comorbidity and associated dysfunction. These preschoolers are likely to require aggressive interventions including psychopharmacology.]]>Mon, 15 Aug 2011 14:06:40 GMT-05:0000004703-200202001-00006http://journals.lww.com/jrnldbp/Fulltext/2002/02001/The_Role_of_Complementary_and_Alternative_Medicine.7.aspx
ABSTRACT. The use of complementary and alternative medicine (CAM) in pediatrics has become widespread. Parents of young children with developmental and behavioral problems such as attention-deficit hyperactivity disorder (ADHD) are particularly drawn to CAM interventions to avoid or decrease use of psychotropic medications. This paper reviews the epidemiology of CAM use for ADHD, describes a conceptual model of CAM, discusses a variety of commonly used therapies for ADHD, and introduces a systematic, pragmatic approach to discussing CAM therapy use with parents.]]>Mon, 15 Aug 2011 14:07:33 GMT-05:0000004703-200202001-00007http://journals.lww.com/jrnldbp/Fulltext/2002/02001/Too_Young_for_Attention_Deficit_Disorder__Views.8.aspx
ABSTRACT. A review of public-school administrative records and interviews with early-childhood directors from special and regular programs were used to collect information about factors associated with outcomes for young children with attention-deficit disorder with or without hyperactivity (AD/HD) in preschool. Special-education preschool administrators and community-based child care and preschool directors differed in their fundamental view of “what works” with preschool AD/HD children, but they agreed in principle on other issues (e.g., public-school providers attested to faith in adult-directed programming; community providers cited child-centered approaches as effective with AD/HD). The records review and interviews indicate that intrinsic program structure, gentle and constant adult help, acceptance of the child, family integrity, gross motor facilities, and attention to comorbidities were seen as positively related to child success. Multiple caregivers, poor understanding of development, failure to foster self-soothing and other personal mastery skills, expectations of perfection, and delegated parenting were identified as negatively related to good outcomes over time for children with AD/HD or similar profiles.]]>Mon, 15 Aug 2011 14:08:24 GMT-05:0000004703-200202001-00008http://journals.lww.com/jrnldbp/Fulltext/2002/02001/Confessions_of_a_Managed_Behavioral_Health_Care.9.aspx
ABSTRACT. The author describes his early association with several pediatric practitioners in Rhode Island in the 1950s who were among the first to use stimulant drugs in the treatment of children with attentional problems. He also discusses some of the later applications of their work. Since the early 1970s there has been a great deal of public interest in and apprehension about the use of these medications in school children. Since the early 1990s there has been concern about the influence of mental health service delivery systems on the prescriptive practices of physicians. Carved-out behavioral health care systems have the potential to improve the standard of care in the pediatric populations they serve.]]>Mon, 15 Aug 2011 14:09:41 GMT-05:0000004703-200202001-00009http://journals.lww.com/jrnldbp/Fulltext/2002/02001/Too_Young_for_ADHD__The_Potential_Role_of_Systems.10.aspx
ABSTRACT. This article discusses a number of issues related to the diagnosis and treatment of children with attention-deficit hyperactivity disorder (ADHD), with specific implications for preschoolers. A brief review of diagnostic and treatment issues for young children is followed by a discussion of developmental issues that contextualize the preschool years and have an impact on cognitive and emotional development underlying self-regulation. The characteristics of the high numbers of children with ADHD receiving services within community-based systems of care and symptom outcomes are reported, as well as a description of the components of the systems of care approach. Recent federal initiatives that impact the care of children with ADHD within community settings are highlighted. It is concluded that the identification and management of preschool children with ADHD can be effective within the context of fully integrated service system approaches.]]>Mon, 15 Aug 2011 14:10:37 GMT-05:0000004703-200202001-00010http://journals.lww.com/jrnldbp/Fulltext/2002/02000/Impact_of_Low_Birth_Weight_on_Attention_Deficit.4.aspx
ABSTRACT. The objective of the study was to evaluate an association between low birth weight (LBW) and attention-deficit hyperactivity disorder (ADHD) attending to potential family-genetic and environmental confounders. We examined 252 ADHD cases (boys and girls) and 231 non-ADHD controls and their parents. All subjects were extensively assessed with structured diagnostic interviews, cognitive assessments, and structured interviews of prenatal, infancy, and delivery complications. ADHD cases were three times more likely to have been born LBW than were non-ADHD controls, after attending to potential confounders such as prenatal exposure to alcohol and cigarettes, parental ADHD, social class, and comorbid disruptive behavior disorders in parents and offspring. If this association was causal, 13.8% of all ADHD cases could be attributed to LBW. These results converge with prior studies documenting similar associations and indicate that LBW is an independent risk factor for ADHD. Children with LBW, however, make up a relatively small proportion of children with ADHD.]]>Mon, 15 Aug 2011 14:11:27 GMT-05:0000004703-200202000-00004http://journals.lww.com/jrnldbp/Fulltext/2002/02000/Patterns_of_Psychotropic_Medication_Use_in_Very.5.aspx
ABSTRACT. Psychotropic medications are increasingly used for very young children. Patterns of use in a well-described group of children 3 years and younger with a diagnostic label of attention-deficit hyperactivity disorder (ADHD) reveal both reasons to use such medications and concerns about how these medications are used. Of 223 children with ADHD, more than half (n = 127) received psychotropic medications in an idiosyncratic manner, both in the specific medication and in use over time. Almost half of the children who were medicated did not have opportunities for monitoring as often as every 3 months, despite the fact that more than half received psychotropic medications for 6 months or longer. Children with comorbid mental health conditions and chronic health conditions were at greater risk for receiving psychotropic medications. These patterns of use demonstrate a compelling need for guidance in psychopharmacological treatment of very young children.]]>Mon, 15 Aug 2011 14:13:07 GMT-05:0000004703-200202000-00005http://journals.lww.com/jrnldbp/Fulltext/2002/04000/Racing_Cain.5.aspx
No abstract available]]>Mon, 15 Aug 2011 14:14:50 GMT-05:0000004703-200204000-00005http://journals.lww.com/jrnldbp/Fulltext/2012/01000/The_New_Attention_Deficit_Hyperactivity_Disorder.12.aspx
No abstract available]]>Tue, 10 Jan 2012 11:11:09 GMT-06:0000004703-201201000-00012http://journals.lww.com/jrnldbp/Fulltext/2012/02000/Associations_Between_Psychiatric_Comorbidities_and.1.aspx
Objective: Children with attention-deficit/hyperactivity disorder (ADHD) often have sleep complaints and also higher rates of psychiatric comorbidities such as mood and anxiety disorders that may affect sleep. The authors hypothesized that children with ADHD and psychiatric comorbidities would have higher overall sleep disturbance scores as measured by a sleep questionnaire than children with ADHD without comorbidities. Methods: This cross-sectional analysis in an academic center studied 317 children with ADHD; 195 subjects had no comorbid conditions, 60 were anxious and 62 were depressed. Participants completed the Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present State, 4th Revised Edition and the Children's Sleep Habits Questionnaire. Results: Median age (range) was 8.9 (6–18.7) years; 78% were male. Median (interquartile range) Total Sleep Disturbance Score (TSDS) on Children's Sleep Habits Questionnaire for subjects with no comorbidities was 44 (40–49); anxiety, 48 (43–54); and depression, 46 (41–52). Compared with subjects without comorbidities, TSDS in anxious subjects was greater (p = .008). TSDS in depressed subjects was not significantly different. Compared with subjects without comorbidities, anxious subjects had higher Bedtime Resistance, Sleep Onset Delay, and Night Wakings subscales (p = .03, .007, and .007, respectively); depressed subjects had higher Sleep Onset Delay and Sleep Duration subscales (p = .003 and .01, respectively). Conclusions: Anxiety in children with ADHD contributed to higher overall sleep disturbance scores, compared with children with ADHD alone. Both comorbidities were associated with higher Sleep Onset Latency subscale scores. Further study of the impact of psychiatric comorbidities on sleep in children with ADHD is warranted.]]>Tue, 19 Jun 2012 10:06:08 GMT-05:0000004703-201202000-00001http://journals.lww.com/jrnldbp/Fulltext/2012/04000/Severity_of_the.6.aspx
Objective: We examined whether severity scores (1 SD vs 2 SDs) of a unique profile of the Child Behavior Checklist (CBCL) consisting of the Anxiety/Depression, Aggression, and Attention (AAA) scales would help differentiate levels of deficits in children with attention-deficit hyperactivity disorder (ADHD). Study Design: Subjects were 197 children with ADHD and 224 without ADHD. We defined deficient emotional self-regulation (DESR) as an aggregate cutoff score of >180 but <210 (1 SD) on the AAA scales of the CBCL (CBCL-DESR) and Severe Dysregulation as an aggregate cutoff score of ≥210 on the same scales (CBCL-Severe Dysregulation). All subjects were assessed with structured diagnostic interviews and a range of functional measures. Results: Thirty-six percent of children with ADHD had a positive CBCL-DESR profile versus 2% of controls (p < .001) and 19% had a positive CBCL-Severe Dysregulation profile versus 0% of controls (p < .001). The subjects positive for the CBCL-Severe Dysregulation profile differed selectively from those with the CBCL-DESR profile in having higher rates of unipolar and bipolar mood disorders, oppositional defiant and conduct disorders, psychiatric hospitalization at both baseline and follow-up assessments, and a higher rate of the CBCL-Severe Dysregulation in siblings. In contrast, the CBCL-DESR was associated with higher rates of comorbid disruptive behavior, anxiety disorders, and impaired interpersonal functioning compared with other ADHD children. Conclusion: Severity scores of the AAA CBCL profiles can help distinguish 2 groups of emotional regulation problems in children with ADHD.]]>Tue, 19 Jun 2012 10:07:43 GMT-05:0000004703-201204000-00006http://journals.lww.com/jrnldbp/Fulltext/2012/04000/Ameliorating_Attention_Problems_in_Children_With.7.aspx
Objective: This pilot study examined whether methylphenidate (MPH) was effective in enhancing cognitive performance and attention for children with sickle cell disease (SCD) with cerebrovascular complications who evidence attention problems. Methods: In this multisite, pilot study, we evaluated 2 separate double-blind controlled clinical trials, including a laboratory trial of the short-term efficacy of MPH, with the second study a 3-week home/school crossover trial evaluating the efficacy of MPH. The laboratory trial included 14 participants between the age of 7 and 16 years. Assessments included measures of sustained attention, reaction time, executive functions, and verbal memory. The home/school trial included 20 participants. The outcome measures were parent and teacher ratings of attention. The first study compared MPH with placebo, while the second trial compared placebo, low-dose (LD) MPH, and moderate-dose MPH. Results: In the laboratory trial, significant effects were revealed for measures of memory and inhibitory control. Parent and teacher reports from the home/school trial indicate that moderate-dose MPH produced superior improvement in attention relative to the placebo and LD MPH. Conclusions: Stimulant medication positively impacted select measures of memory and inhibitory control in some children with SCD. Attention, as rated by parent and teachers, was improved for a greater number of children and adolescents on higher doses of MPH relative to LD MPH and placebo. Stimulant medication may provide an effective intervention for some children with SCD and cerebrovascular complications who demonstrate attention problems.]]>Tue, 19 Jun 2012 10:08:12 GMT-05:0000004703-201204000-00007http://journals.lww.com/jrnldbp/Fulltext/2012/05000/Attention_Deficit_Hyperactivity_Disorder_Symptoms.4.aspx
Objective: Attentional problems, hyperactivity, and impulsivity have been described as behavioral features associated with sex chromosome aneuploidy (SCA). In this study, the authors compare attention-deficit hyperactivity disorder (ADHD) symptoms in 167 participants aged 6 to 20 years with 4 types of SCA (XXY n = 56, XYY n = 33, XXX n = 25, and XXYY n = 53). They also evaluate factors associated with ADHD symptomatology (cognitive and adaptive scores, prenatal vs postnatal ascertainment) and describe the clinical response to psychopharmacologic medications in a subset of patients treated for ADHD. Methods: Evaluation included medical and developmental history, cognitive and adaptive functioning assessment, and parent and teacher ADHD questionnaires containing DSM-IV criteria. Results: In the total study group, 58% (96/167) met DSM-IV criteria for ADHD on parent-report questionnaires (36% in XXY, 52% in XXX, 76% in XYY, and 72% in XXYY). The Inattentive subtype was most common in XXY and XXX, whereas the XYY and XXYY groups were more likely to also have hyperactive/impulsive symptoms. There were no significant differences in Verbal, Performance, or Full Scale IQ between children with symptom scores in the ADHD range compared with those below the ADHD range. However, adaptive functioning scores were significantly lower in the group whose scores in the ADHD range were compared with those of the group who did not meet ADHD DSM-IV criteria. Those with a prenatal diagnosis of XXY were less likely to meet criteria for ADHD compared with the postnatally diagnosed group. Psychopharmacologic treatment with stimulants was effective in 78.6% (66/84). Conclusions: Children and adolescents with SCA are at increased risk for ADHD symptoms. Recommendations for ADHD evaluation and treatment in consideration of other aspects of the SCA medical and behavioral phenotype are provided.]]>Tue, 19 Jun 2012 10:09:14 GMT-05:0000004703-201205000-00004http://journals.lww.com/jrnldbp/Fulltext/2012/05000/Can_Parent_Reports_Serve_as_a_Proxy_for_Teacher.7.aspx
Objective: While American Academy of Pediatrics guidelines recommend obtaining symptom reports from both parents and teachers when treating children with attention-deficit hyperactivity disorder (ADHD), information from parents is easier to obtain and practitioners may prefer to rely solely on parent report when managing medications. There are, however, few empirical data on the relationship between parent and teacher reports during medication management of ADHD. This study examined the relationship between parent and teacher reports of symptoms of ADHD during a clinical trial. Methods: A study to improve medication management of ADHD was conducted in 24 pediatric practices with 270 children. Children meeting criteria for ADHD were randomized by practice to treatment-as-usual or specialized care groups, with data combined from the groups to examine parent-teacher agreement. Parent and teacher reports on the ADHD Rating Scale-IV were obtained at pretreatment, 4 months, and 12 months follow-up. Results: At each assessment, correlations between parent and teacher ratings were statistically significant, but the magnitudes of the correlations were low, accounting for no more than approximately 17% of the variance between measures. Correlations between change scores on parent and teacher ratings were statistically significant but low for Total and Inattentive scales and not significant for the Hyperactive-Impulsive scale. For agreement on extreme scores, 6 of 9 kappas were statistically significant but all were unacceptably low. Conclusions: Agreement between parent and teacher ratings of symptoms of ADHD is too low for clinicians to rely on parent reports while managing medications. Teacher reports are still needed to ensure optimal management.]]>Tue, 19 Jun 2012 10:09:47 GMT-05:0000004703-201205000-00007http://journals.lww.com/jrnldbp/Fulltext/2012/04000/Clinical_Utility_of_the_Vanderbilt_ADHD_Diagnostic.4.aspx
Objective: To evaluate the clinical utility of the cutoff recommendations for the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) comorbidity screening scales provided by the American Academy of Pediatrics/National Initiative for Children's Healthcare Quality and to examine alternative cutoff strategies for identifying and ruling out disorders commonly comorbid with attention-deficit/hyperactivity disorder. Methods: A sample of 215 children (142 with attention-deficit/hyperactivity disorder), ages 7 to 11 years, participated in the study. Parents completed the VADPRS and were administered a diagnostic interview to establish diagnoses of oppositional defiant disorder (ODD), conduct disorder (CD), anxiety, and depression. The clinical utility of the VADPRS comorbidity screening scales were examined. Results: The recommended American Academy of Pediatrics/National Initiative for Children's Healthcare Quality cutoff strategies did not have adequate clinical utility for identifying or ruling out comorbidities, with the exception of the VADPRS ODD cutoff strategy, which reached adequate levels for ruling out a diagnosis of ODD. An alternative cutoff approach using total sum scores was superior to the recommended cutoff strategies across all diagnoses in terms of ruling out a diagnosis, and this was particularly evident for anxiety/depression. Several individual items on the ODD and CD scales also had acceptable clinical utility for ruling in diagnoses. Conclusions: The VADPRS comorbidity screening scales may be helpful in determining which children likely do not meet diagnostic criteria for ODD, CD, anxiety, or depression. This study suggests that using a total sum score provides the greatest clinical utility for each of these comorbidities and demonstrates the need for further research examining the use of dimensional assessment strategies in diagnostic decision making.]]>Tue, 19 Jun 2012 10:10:20 GMT-05:0000004703-201204000-00004http://journals.lww.com/jrnldbp/Fulltext/2012/06000/Late_Preterm_Birth_by_Delivery_Circumstance_and.4.aspx
Objective: Late-preterm birth (LPB, 34–36 wk) has been associated with an increased risk of attention problems in childhood relative to full-term birth (FTB, ≥37 wk), but little is known about factors contributing to this risk. The authors investigated the contributions of clinical circumstances surrounding delivery using follow-up data from the Pregnancy Outcomes and Community Health (POUCH) Study. Methods: Women who delivered late preterm or full term and completed the sex- and age-referenced Conners' Parent Rating Scales—Short Form: Revised were included in the present analysis (N = 762; children's age, 3–9 y). The Conners' Parent Rating Scales—Short Form: Revised measures dimensions of behavior linked to attention problems, including oppositionality, inattention, hyperactivity, and a global attention problem index. Using general linear models, the authors evaluated whether LPB subtype (medically indicated [MI] or spontaneous) was associated with these dimensions relative to FTB. Results: After adjustment for parity, sociodemographics, child age, and maternal symptoms of depression and serious mental illness during pregnancy and at the child survey, only MI LPB was associated with higher hyperactivity and global index scores (mean difference from FTB = 3.8 [95% confidence interval {CI}: 0.5, 7.0] and 3.1 [95% CI 0.0, 6.2]). These findings were largely driven by children between 6 and 9 years. Removal of women with hypertensive disorders during pregnancy (N = 85) or placental findings related to hypertensive conditions (obstruction, decreased maternal spiral artery conversion; N = 134) reduced the differences below significance thresholds. Conclusions: Among LPBs, only MI LPB was associated with higher levels of parent-reported childhood attention problems, suggesting that complications motivating medical intervention during the late-preterm period mark increased risk for such problems. Hypertensive disorders seem to play a role in these associations.]]>Tue, 19 Jun 2012 10:11:48 GMT-05:0000004703-201206000-00004http://journals.lww.com/jrnldbp/Fulltext/2013/02000/_When_the_Prescription_Pad_Is_Not_Enough___.9.aspx
CASE: Jose is a 13-year-old boy who presents to his primary care provider after struggling in school for many years. When he was in the first grade, he was diagnosed at a tertiary center with attention-deficit hyperactivity disorder. Multiple medication trials have produced few benefits and many side effects including poor sleep, morbid thoughts, lack of motivation, and, according to his parents, “he seemed like a robot.”
He comes now for his annual physical in April, and the parents tell you that the school is threatening that he be retained in the seventh grade. Parents are very adamant they do not want to try another medication. They have brought you their own and his advisor’s Vanderbilt’s, which each endorse 7 of 9 inattentive symptoms including trouble organizing, poor attention to detail, and easily distracted and forgetful in daily activities.
His birth history and developmental history before beginning formal schooling are unremarkable. His first language was English whereas his parents speak Spanish to each other but not the children. He is healthy and without a history of head trauma, seizures, meningitis, or lead poisoning. An aunt has “learning problems.”
Jose’s family lives in a crowded section of a large urban area. They share an apartment with another family, and both parents are employed full time with his father holding 2 full time jobs working double shifts. Their annual income is at the poverty line. There are 4 children in the family aged between 6 and 13 years.
His school has been deemed a “recovery school” because of performing below standard on district-wide achievement tests. His classroom has 27 students, many of whom are English language learners, and he is not on an individualized education plan or 504 accommodations.
The family is very concerned about the possibility of retention but have decided that “medicine does not help,” and they look to you for other recommendations. Where do you go next?]]>Wed, 24 Jul 2013 16:20:19 GMT-05:0000004703-201302000-00009http://journals.lww.com/jrnldbp/Fulltext/2013/10000/ADHD_Is_a_Risk_Factor_for_Overweight_and_Obesity.5.aspx
Objective: Although hyperactivity would seem to increase energy expenditure, attention-deficit hyperactivity disorder (ADHD) appears to increase the risk for being overweight. This study examined the body mass index (BMI) in children with ADHD and its relationship with age, gender, ADHD and comorbid symptom severity, inhibitory control, developmental coordination disorder, sleep duration, and methylphenidate use.
Method: Participants were 372 Dutch children with ADHD combined type aged 5 to 17 years participating in the International Multicenter ADHD Genetics (IMAGE) study. We categorized BMI according to international age- and gender-specific reference values and calculated BMI-standard deviation scores (BMI-SDS). The control population was matched for age, gender, and ethnicity and originated from the same birth cohort as the ADHD group. Inhibitory control was measured by the computerized Stop-signal task. Prevalence differences of underweight, overweight, and obesity between groups were expressed in odds ratios. We used linear regression analyses with gender, age, parent- and teacher-rated ADHD and comorbid scores, inhibitory control, sleep duration, motor coordination, and methylphenidate use to predict BMI-SDS.
Results: Boys with ADHD aged 10 to 17 years and girls aged 10 to 12 years were more likely to be overweight than children in the general Dutch population. Younger girls and female teenagers, however, seemed to be at lower risk for being overweight. Higher oppositional behavior and social communication problems related to higher BMI-SDS scores, whereas more stereotyped behaviors related to lower BMI-SDS scores. We found no effects of the other examined associated risk factors on BMI-SDS.
Conclusions: Attention-deficit hyperactivity disorder in boys is a risk factor for overweight. In girls with ADHD, the prevalence of overweight is age dependent and most pronounced in girls aged 10 to 12 years. They have a 4-fold risk of being obese. Higher oppositional and social communication problems pose an increased risk for overweight, whereas sleep duration, motor coordination problems, and methylphenidate use do not.]]>Tue, 14 Apr 2015 11:27:38 GMT-05:0000004703-201310000-00005http://journals.lww.com/jrnldbp/Fulltext/2013/10000/Bullying_and_ADHD___Which_Came_First_and_Does_it.12.aspx
CASE: Aiden, a 13-year-old boy in the sixth grade who is relatively new to your practice, is seen for follow-up after his routine physical last month when you noted concerns for possible attention-deficit hyperactivity disorder (ADHD) and gave the family Vanderbilt Scales to complete. Aiden has a family history of ADHD, specific learning disabilities, and mood disorder.
His mother reports that she is concerned about how Aiden is doing at school; his teachers are complaining that he is not doing his work, and she is worried that he may be kept back in school. Aiden first began having trouble in the third grade. He was retained in the fourth grade for academic and behavioral reasons. Now his mother has been receiving calls about him not paying attention, distracting others, and staring at his paper. At home, he does not want to do homework and gets very frustrated. In fifth grade, he had a psychoeducational evaluation and was found not eligible for services. His achievement testing showed average scores in reading, math, and writing. Cognitive testing demonstrated average scores for verbal and nonverbal abilities and memory but was significantly below average for processing speed. Aiden continues to have problems now in into the sixth grade.
You speak with Aiden in the office and ask him about school. He says, “It's bad. I'm failing.” He believes his major problems at school are that he is not doing his homework, he easily becomes frustrated, and he argues with the teachers. He has supportive relationships with his family and friends at school. He gets along well with some of his teachers, noting that he loves his science teacher even though she is tough and “gives hard homework.” He describes his history teacher as “annoying.” When you ask what he means he states this teacher “Can be not nice and says mean things. She picks on me a lot.” His description is consistent with the use of shaming as a behavior he experiences at school.
You review the completed parent and teacher Vanderbilt forms; both are consistent and concerning for combined type ADHD. You discuss the diagnosis of ADHD with his mother and both agree to revisit pharmacotherapy in September when the school year resumes. You give her resources on ADHD and classroom accommodations and discuss requesting a 504 plan at school. You also discuss behavioral therapy to better address his self-regulation skills.
A week later, you receive a telephone call from Aiden's mother. “Aiden got home today and he is more upset than I have ever seen him! His teacher told him in front of the class that he would probably stay back a year and now he is saying there is no point in going to school.” She is not aware if retention has been recommended for Aiden.
What would you say to Aiden's mother? What would you do next?]]>Tue, 14 Apr 2015 11:28:40 GMT-05:0000004703-201310000-00012http://journals.lww.com/jrnldbp/Fulltext/2013/11000/Relationship_Between_Polysomnographic_Sleep.7.aspx
Objective: To describe the relationship between sleep architecture and behavioral measures in unmedicated children and adolescents with Tourette syndrome (TS), attention-deficit hyperactivity disorder (ADHD), TS and comorbid ADHD (TS + ADHD), and healthy controls. The study also set out to examine differences in sleep architecture with each diagnosis.
Method: A cross-sectional, 2-night consecutive polysomnographic sleep study was conducted in 90 children. All participants were matched for age, gender, and level of intelligence.
Results: Scores on the Child Behavior Checklist delinquency measure were modestly but significantly correlated with the number of movements during REM sleep (r = .36, p = .003). Significant correlations were also noted among the number of total arousals and arousals from slow wave sleep (SWS), and scores on the measures of conduct disorder, hyperactivity/immaturity, and restless/disorganized behaviors. There were a few significant differences in sleep architecture among the diagnostic groups. The ADHD-only group exhibited a significantly higher number of total arousals (p < .01) and arousals from SWS (p < .01) compared with the other three study groups.
Discussion: Our findings indicate that children with TS and/or ADHD and who have more arousals from sleep are significantly more likely to have issues with conduct disorder, hyperactivity/immaturity, and restless/disorganized behavior. It was also noted that having ADHD, alone or comorbid with TS, is associated with a significantly greater number of movements during both non-REM and REM sleep. This study underscores the compelling need for the diagnosis and treatment of any sleep disorders in children with TS and/or ADHD so as to facilitate better management of problem behaviors.]]>Tue, 14 Apr 2015 11:29:47 GMT-05:0000004703-201311000-00007http://journals.lww.com/jrnldbp/Fulltext/2014/01000/Neurofeedback_and_Cognitive_Attention_Training_for.3.aspx
Objective: To evaluate the efficacy of 2 computer attention training systems administered in school for children with attention-deficit hyperactivity disorder (ADHD).
Method: Children in second and fourth grade with a diagnosis of ADHD (n = 104) were randomly assigned to neurofeedback (NF) (n = 34), cognitive training (CT) (n = 34), or control (n = 36) conditions. A 2-point growth model assessed change from pre-post intervention on parent reports (Conners 3-Parent [Conners 3-P]; Behavior Rating Inventory of Executive Function [BRIEF] rating scale), teacher reports (Swanson, Kotkin, Agler, M-Flynn and Pelham scale [SKAMP]; Conners 3-Teacher [Conners 3-T]), and systematic classroom observations (Behavioral Observation of Students in Schools [BOSS]). Paired t tests and an analysis of covariance assessed change in medication.
Results: Children who received NF showed significant improvement compared with those in the control condition on the Conners 3-P Attention, Executive Functioning and Global Index, on all BRIEF summary indices, and on BOSS motor/verbal off-task behavior. Children who received CT showed no improvement compared to the control condition. Children in the NF condition showed significant improvements compared to those in the CT condition on Conners 3-P Executive Functioning, all BRIEF summary indices, SKAMP Attention, and Conners 3-T Inattention subscales. Stimulant medication dosage in methylphenidate equivalencies significantly increased for children in the CT (8.54 mg) and control (7.05 mg) conditions but not for those in the NF condition (0.29 mg).
Conclusion: Neurofeedback made greater improvements in ADHD symptoms compared to both the control and CT conditions. Thus, NF is a promising attention training treatment intervention for children with ADHD.]]>Tue, 14 Apr 2015 11:31:07 GMT-05:0000004703-201401000-00003http://journals.lww.com/jrnldbp/Fulltext/2014/11000/_Complex__Attention_Deficit_Hyperactivity.5.aspx
Objective: Current recommendations for evaluation and diagnosis of attention-deficit hyperactivity disorder (ADHD) are meant for primary care settings and may not adequately address the needs of children seen in subspecialty developmental-behavioral pediatric settings who may have higher rates of comorbid developmental, learning, and psychiatric disorders. The authors sought to characterize the diagnostic complexity of school-aged children diagnosed with ADHD after comprehensive multidisciplinary evaluation in a subspecialty developmental-behavioral pediatric clinic.
Methods: The authors conducted a retrospective medical record review of 144 patients aged 7 to 11 years who were consecutively evaluated by an interdisciplinary team (developmental-behavioral pediatrician, psychologist, educator) in a school-age clinic within a developmental-behavioral pediatrics tertiary care center from January 1, 2009 to December 31, 2009.
Results: After comprehensive evaluation, rates of ADHD diagnosis increased from 32.6% (n = 47) preevaluation to 54.2% (n = 78) postevaluation (p < .0001). Rates of learning disorders among children receiving a final diagnosis of ADHD increased from 2.6% (n = 2) preevaluation to 50% (n = 39) postevaluation. (p < .0001). Among children receiving a final diagnosis of ADHD, 73.1% (n = 57) were diagnosed with at least 1 comorbid psychiatric, developmental, or learning disorder.
Conclusions: Among school-aged children diagnosed with ADHD in a developmental-behavioral pediatric subspecialty setting, a comprehensive evaluation including developmental, neuropsychological, and educational assessments yielded high rates of comorbid psychiatric, developmental, and learning disorders. This supports the need to provide comprehensive interdisciplinary assessment for such children to ensure the identification and treatment of not only the core symptoms of ADHD but also the comorbidities that may otherwise go unrecognized and therefore not optimally treated.]]>Tue, 14 Apr 2015 11:31:36 GMT-05:0000004703-201411000-00005http://journals.lww.com/jrnldbp/Fulltext/2014/02000/Mediators_of_Methylphenidate_Effects_on_Math.3.aspx
Objective: Stimulant medications, such as methylphenidate (MPH), improve the academic performance of children with attention-deficit hyperactivity disorder (ADHD). However, the mechanism by which MPH exerts an effect on academic performance is unclear. We examined MPH effects on math performance and investigated possible mediation of MPH effects by changes in time on-task, inhibitory control, selective attention, and reaction time variability.
Methods: Children with ADHD aged 7 to 11 years (N = 93) completed a timed math worksheet (with problems tailored to each individual's level of proficiency) and 2 neuropsychological tasks (Go/No-Go and Child Attention Network Test) at baseline, then participated in a 4-week, randomized, controlled, titration trial of MPH. Children were then randomly assigned to their optimal MPH dose or placebo for 1 week (administered double-blind) and repeated the math and neuropsychological tasks (posttest). Baseline and posttest videorecordings of children performing the math task were coded to assess time on-task.
Results: Children taking MPH completed 23 more math problems at posttest compared to baseline, whereas the placebo group completed 24 fewer problems on posttest versus baseline, but the effects on math accuracy (percent correct) did not differ. Path analyses revealed that only change in time on-task was a significant mediator of MPH's improvements in math productivity.
Conclusions: MPH-derived math productivity improvements may be explained in part by increased time spent on-task, rather than improvements in neurocognitive parameters, such as inhibitory control, selective attention, or reaction time variability.]]>Tue, 14 Apr 2015 11:33:25 GMT-05:0000004703-201402000-00003http://journals.lww.com/jrnldbp/Fulltext/2014/06000/Attention_Deficit_Hyperactivity,_Fetal_Alcohol.6.aspx
CASE: Thomas is a 5-year 6-month-old boy whose parents requested an urgent care appointment because he has recently been suspended from kindergarten stating “and his doctor must see him before he can come back.” His suspension from kindergarten was due to kicking and biting his classmates, but he has also become increasingly aggressive at home. His teacher reported that he has always had a high activity level and difficulty shifting attention between tasks, as well as noncompliance with rules and directions. He is noted to have learning challenges and is showing difficulties in the concept of numbers and letter sounds.
The practice has followed Thomas since his healthy birth. He has a history of delayed language development, and he received early intervention services from 2 years of age. He spoke his first word at 2 years 6 months. He started a half-day preschool program at 3 years of age. He had difficulty acclimating to preschool, interacting with peers, and was described as “hyperactive” by his teachers. His program was modified to decrease his time having to sit in a circle time, and he often required the support of the paraprofessional in the classroom.
His parents have always described him as a “difficult child.” He gets frustrated easily and can tantrum for up to 2 hours multiple times in a week when his immediate needs or requests are not met. He has difficulty falling asleep, has frequent night awakenings, and often has trouble getting back to sleep. His self-help skills are poor, and he has difficulty with activities such as brushing his teeth and dressing. His parents report that he does not seem to remember rules from day to day. He was evaluated at 5 years of age and diagnosed with Attention Deficit Hyperactivity Disorder, but his response to stimulants has been limited.
Thomas is an only child. His parents are college educated and professionally employed. They deny drug use, domestic violence, and guns in the home. They reported that prior to the pregnancy, they enjoyed “partying” with friends on the weekends, but Thomas's mother reported that she stopped drinking as soon as she realized she was pregnant.
All are wondering whether this child might have a fetal alcohol spectrum disorder, although he seems to have no clear facial dysmorphology. It is unsure what the next step might be and if there is value added in pursuing this diagnosis. What do you do next?]]>Tue, 14 Apr 2015 11:35:58 GMT-05:0000004703-201406000-00006http://journals.lww.com/jrnldbp/Fulltext/2014/09000/Update_on_Long_term_Stimulant_Medication_Treatment.6.aspx
No abstract available]]>Tue, 14 Apr 2015 11:37:42 GMT-05:0000004703-201409000-00006http://journals.lww.com/jrnldbp/Fulltext/2015/02000/Improved_but_Still_Impaired___Symptom_Impairment.8.aspx
Objective: To explore correspondences between the trajectories of symptoms and impairments in youth with attention-deficit hyperactivity disorder (ADHD) being treated by in primary care settings.
Methods: Parents of youth (n = 1976) rated their child's symptoms of inattention and hyperactivity/impulsivity, and impairment across a variety of domains. Multilevel models were estimated to characterize the trajectories of symptoms and impairment and to determine whether changes in symptom dimension trajectories corresponded to changes in impairment trajectories over time.
Results: Results indicated that symptom dimensions initially improved, then leveled off, and then decreased minimally. However, impairment domains remained largely stable (i.e., neither improved nor worsened). Improvement in inattention symptoms were associated with improved ratings of writing impairment, and improved ratings of hyperactivity/impulsivity symptoms were associated with improved relationship with peers.
Conclusions: Youths with ADHD who are treated by their community pediatrician tend to initially improve in their symptom presentation, although this symptom reduction plateaus and is not associated with corresponding improvements in most areas of impairment.]]>Tue, 14 Apr 2015 11:40:47 GMT-05:0000004703-201502000-00008http://journals.lww.com/jrnldbp/Fulltext/2015/02000/Apraxia,_Autism,_Attention_Deficit_Hyperactivity.10.aspx
CASE: Gio is a bilingual 6-year 10-month-old boy new to your practice who presents for an unscheduled visit with concerns for speech and language delay. He was born in Portugal, and his native language is Portuguese. When he was 21 months old, his family moved to Italy and then moved to the United States 3 years later. He had very little contact with other children while living in Italy, but his parents report that he has made friends quickly in the United States. His family speaks Portuguese at home, although his father is fluent in English.
He started school 3 months after moving to the United States and is currently repeating kindergarten. He is in a sheltered English classroom with several other students who speak Portuguese. He is able to understand and follow directions in English. A recent school evaluation revealed solidly average nonverbal reasoning skills and relative weaknesses in verbal reasoning and working memory. His speech is described as unintelligible in conversation, both in English and Portuguese.
Results of a special education evaluation qualified him for services with a bilingual therapist. His teachers are very concerned that he may have autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). They describe him as having limited interest in other children, poor eye contact, and hypersensitivities. He wanders at recess. He is very skilled at art and seems to prefer to draw rather than interact with others. He needs constant support and redirection throughout the school day. He has difficulty putting on his coat, using playground equipment, and following daily classroom routines. On the Vanderbilt Rating Scale, his teacher endorses 17 of 18 ADHD symptoms as present often or very often and significant impairment in his performance.
Gio presents to your clinic as a relatable young boy with childhood apraxia of speech. Only his productions of single words and short routine phrases are intelligible. He attempts to engage in conversation but averts his gaze and becomes frustrated when asked to repeat things. Scores on the Parent Conners Rating Scale and Social Responsiveness Scale are not elevated. When you bring up school's concerns, his father describes feeling somewhat badgered by his teachers about possibility of ASD.
School is considering placement in an inclusion classroom for children with ASD. What do you recommend? How would you advise his parents?]]>Tue, 14 Apr 2015 11:42:20 GMT-05:0000004703-201502000-00010http://journals.lww.com/jrnldbp/Fulltext/2015/07000/Patient_Centered_Medical_Home_and_Family_Burden_in.2.aspx
Objective: Attention-deficit hyperactivity disorder (ADHD) can impair child health and functioning, but its effects on the family's economic burden are not well understood. The authors assessed this burden in US families of children with ADHD, and the degree to which access to a patient-centered medical home (PCMH) might reduce this burden.
Methods: We conducted cross-sectional analyses of 2005–2006 and 2009–2010 National Surveys of Children with Special Health Care Needs, focusing on families of children with ADHD. They defined family economic burden as (1) family financial problems (annual expenses for the child's health care or illness-related financial problems for the family) and/or (2) family employment problems (job loss, work time loss, or failure to change jobs to avoid insurance loss). Relative risk models assessed associations between PCMH and family economic burden, adjusted for child age, sex, ethnicity, ADHD severity, poverty status, caregiver education, and insurance.
Results: In 2009, 26% of families reported financial problems because of the child's ADHD, 2.1% reported out-of-pocket expenses >5% of income, and 36% reported employment problems. Only 38% reported care that met all 5 criteria for a PCMH (similar to rates in 2005–2006). In multivariable analysis, care in a PCMH was associated with 48% lower relative risk (RR) of financial problems (RR = 0.52, p < .001) and 36% lower relative risk of employment problems (RR = 0.64, p < .001). Among PCMH components, family-centered care and care coordination were more strongly associated with lower burden.
Conclusions: The economic burdens of families with ADHD are significant but may be alleviated by family-centered care and care coordination in a medical home.]]>Thu, 09 Jul 2015 08:11:32 GMT-05:0000004703-201507000-00002http://journals.lww.com/jrnldbp/Fulltext/2015/07000/Patient_Centered_Medical_Home_and_Family_Burden_in.2.aspx
Objective: Attention-deficit hyperactivity disorder (ADHD) can impair child health and functioning, but its effects on the family's economic burden are not well understood. The authors assessed this burden in US families of children with ADHD, and the degree to which access to a patient-centered medical home (PCMH) might reduce this burden.
Methods: We conducted cross-sectional analyses of 2005–2006 and 2009–2010 National Surveys of Children with Special Health Care Needs, focusing on families of children with ADHD. They defined family economic burden as (1) family financial problems (annual expenses for the child's health care or illness-related financial problems for the family) and/or (2) family employment problems (job loss, work time loss, or failure to change jobs to avoid insurance loss). Relative risk models assessed associations between PCMH and family economic burden, adjusted for child age, sex, ethnicity, ADHD severity, poverty status, caregiver education, and insurance.
Results: In 2009, 26% of families reported financial problems because of the child's ADHD, 2.1% reported out-of-pocket expenses >5% of income, and 36% reported employment problems. Only 38% reported care that met all 5 criteria for a PCMH (similar to rates in 2005–2006). In multivariable analysis, care in a PCMH was associated with 48% lower relative risk (RR) of financial problems (RR = 0.52, p < .001) and 36% lower relative risk of employment problems (RR = 0.64, p < .001). Among PCMH components, family-centered care and care coordination were more strongly associated with lower burden.
Conclusions: The economic burdens of families with ADHD are significant but may be alleviated by family-centered care and care coordination in a medical home.]]>Thu, 09 Jul 2015 08:11:34 GMT-05:0000004703-201507000-00002